Francis Howell North Knights

FHN 2022-23 Midstates Consent Form

MIDSTATES CLUB HOCKEY ASSOCIATION
www.midstateshockey.us
Twitter @midstateshockey

Definitive Emergency Medical Care Consent

I, the undersigned parent of

* Players Name:

do hereby consent to have prompt definitive emergency medical care administered to the aforementioned member of my family in my absence, in so doing; I release the administering facility and/or individuals from responsibility for medical service performed. The Midstates Club Hockey Association and/or its Club hockey members and representatives are hereby absolved from responsibility for subsequent consequences occurring there from. If necessary contact our child’s doctor.

* Physician Name:

* Office Phone:

Exchange:

Physician Home Phone (if known):

I understand that entering my name below constitutes a legal signature confirming that I acknowledge and agree that the above information to be true to the best of my knowledge.

* Parent or Legal Guardian:

* Date:

* Emergency Contact Name:

* Emergency Contact Number:

Please note if child has an allergy or is allergic to any medication.

NOTE: This form is to be kept by the Club and taken to all practices/games, so that it is available if necessary.

For Mid-States Hockey information contact Barb Collumbien at 314-575-7069

MEDICAL HISTORY FORM
(COMPLETION OF THIS PORTION OF THE FORM IS OPTIONAL)

PLEASE COMPLETE THE FOLLOWING:
If the answer to any of the following questions is or was yes, please describe the problem and its implications for proper first aid treatment on a separate piece of paper.

Have you had (or do you presently have) any of the following?

Head injury (concussion, skull fracture):

Fainting spells:

Convulsions/epilepsy:

Neck or back injury:

Asthma:

High blood pressure:

Kidney problems:

Hernia:

Diabetes:

Heart murmur:

Allergies:

Other Please Specify:

Injuries to:

Knee:

Shoulder:

Ankle:

Fingers:

Arm:

Other please Specify:

Impaired Vision:

Impaired Hearing:

Other:

Have you had a recent tetanus booster?:

Date of Tetanus Booster:

Are you taking any medications we should be aware of?:

What? and Why?:

Has the doctor placed any restrictions on your activity?:

Explain:

By submitting this registration form and digitally signing your name below you agree that all of the above information is correct to your knowledge.

* Digital Signature:

* indicates required fields

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FHN 2022-23 Midstates Consent Form