Medical History Card Participant Info Participant First Name: Participant Last Name: Participant Phone: Participant Email: Participant Date of Birth: Date of Birth (YYYY/MM/DD): Emergency Contact DURING PROGRAM HOURS: Name/Relation:Phone: Name/Relation:Phone: Alternative Contact/ additional numbers: Family Doctor/phone: Relevant Medical History: Medications: Does the athlete carry and know how to administer their own medication? -please advise the Program Director:*YesNoN/A Allergies (please bring to the attention of the coach): Previous Injuries: Any other relevant information NOTE: This card will be kept with the team at all times. Medical information is confidential and this card will be available to team coaches and managers. Your Name:* Date: MinimizeSign and Submit Signature (or Parent/Guardian if individual is a minor):* Clear Submit
