OMHA Medical Information Sheet
This information will be use by the Team Safety. This will help the Safety Person assist players should they become ill or injured. This form also authorizes them to seek emergency medical attention for a player if they are injured in a practice/game and their parent/guardian isn't present or can't be reached. Complete this form with all the details that match your child's medical file.
Player Name*
First Name Last Name
Date of Birth*
Month Day Year
Address*
Street Address
Street Address Line 2
City Province
Postal Code
Home Phone*
Area Code Phone Number
Cell Phone*
Area Code Phone Number
Provincial Health Care Number
(Optional)

Parent/Guardian & Emergency Contact Information
Mother's Name*
First Name Last Name
Father's Name*
First Name Last Name
Mother's Business Number
Area Code Phone Number
Father's Business Number
Area Code Phone Number
Alternate Emergency Contact (If parents/guardians are not available)*
First Name Last Name
Telephone*
Area Code Phone Number
Address*
Street Address
Street Address Line 2
City Province
Postal Code

Medical Information
Doctor's Name
Telephone*
Area Code Phone Number
Dentist's Name
Telephone*
Area Code Phone Number
* Before a player participates in a hockey program, any medical condition or injury problem should be checked by that individual's family physician.
Date of last completed physical examination:*
Month Day Year
Date

Medications:*
If none, enter N/A
Allergies:*
If none, enter N/A
Recent Injuries:*
If none, enter N/A
Any Information not covered above:*
If none, enter N/A
*
I understand that it is my responsibility to keep the team Safety Person advised of any change in the above information as soon as possible. In the event of a medical emergency and that no one can be contacted, team management will arrange to take my child to the hospital or a physician if deemed necessary.
*
I hereby authorize the physician and nursing staff to undertake examination, investigation and necessary treatment of my child.
*
I also authorize release of information to appropriate people (coach, physician) as deemed necessary.
Date:
Month Day Year
Date
Signature of Parent or Guardian:*
By signing you agree to the conditions stated above Clear
Should be Empty:

	Yes	No
Previous history of concussions
Fainting episodes during exercise
Epileptic
Wear glasses
Are lenses shatterproof
Wears contact lenses
Wears dental appliance
Hearing problem
Asthma
Trouble breathing during exercise
Heart Condition
Medication
Allergies
Has any health problem that would interfere with participation on a hockey team
Has an illness that lasted more that a week and required medical attention in the past year
Has had injuries requiring medical attention in the past year
Has been admitted to hospital in the last year
Surgery in the last year
Hepatitis B vaccination

Parent/Guardian & Emergency Contact Information

Medical Information