Player Details And Medical History Form

In the unlikely event your child requires first aid or emergency care, this form is to enable the first responder to have all appropriate information in order to be able to provide aid in a safe and efficient manner. The information provided will only be accessed by the Vipers coaches, will be stored in a secure manner and will only be shared with appropriate emergency responders if and when required.

Upload Player Photo (recent photo please)

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Player Name*

First NameLast Name

Player Birth Date*

MonthDayYear

NHS number (or European Equivalent)*

Gender

MaleFemale

Player Permanent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent / Guardian Emergency contact name

Relationship to child

MotherFatherGuardianOther

Emergency contact phone number

Emergency contact Email

example@example.com

Has the player had in the past or does the player currently have any of the following: (check any that apply)

If you answered yes to any of the above, please provide details.

If asthma was selected does the player have a puffer, and what medication is in your puffer, what is the recommended dose for a mild and for a severe attack.

You agree to ensure that the appropriate asthma medication is brought with the player and provided to coaches prior to all training, games and club activities, otherwise the player will be unable to participate.

Yes

Please list any previous sports injuries, approximate dates, and whether or not it is still a problem.

Does the player suffer with any allergy to any medication such as (select all that apply)

Does the player suffer with any other allergies such as (select all that apply)

If yes, please provide details including emergency medicines such as an Autoinjector (epinephrine) and application

If an auto-injector is required please confirm that you will provide two devices to accompany the player at each training session, match and team participation activity, (if the devices are not provided participantion will not be allowed and you will be asked to collect your child)

YesNot applicable

Please list any other medications, prescription or non-prescription, that the player takes regularly.

Please include multivitamins, nutritional supplements, naturopathic medications, etc.

Do you have a family history of cardiac conditions, heart disease or stroke?

YesNo

If yes please provide details

Have you ever (to your knowledge) had a concussion/concussions?

YesNo

Are your pupils the same size?

YesNo

If you have had a concussion or concussions, please list the date(s) and circumstance(s) as accurately as possible.

Do you consent to have this information shared with the coaches, and if necessary, on-field medical personnel, Paramedics or other first responders, or hospital staff?*

YesNo (if no then the player will not be able to participate)

Please share any other details you feel are relevant.

Player Details & Medical History