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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):
Yes
No
Fainting spells:
Yes
No
Convulsions/epilepsy:
Yes
No
Neck or back injury:
Yes
No
Asthma:
Yes
No
High blood pressure:
Yes
No
Kidney problems:
Yes
No
Hernia:
Yes
No
Diabetes:
Yes
No
Heart murmur:
Yes
No
Allergies:
Yes
No
Other Please Specify:
Injuries to:
Knee:
Yes
No
Shoulder:
Yes
No
Ankle:
Yes
No
Fingers:
Yes
No
Arm:
Yes
No
Other please Specify:
Impaired Vision:
Yes
No
Impaired Hearing:
Yes
No
Other:
Have you had a recent tetanus booster?:
Yes
No
Date of Tetanus Booster:
Are you taking any medications we should be aware of?:
Yes
No
What? and Why?:
Has the doctor placed any restrictions on your activity?:
Yes
No
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