2012 ROYAL CANADIAN LEGION ATHLETIC CAMP
GENERIC ATHLETE HEALTH RECORD
IT IS IMPORTANT TO COMPLETE, DATE, SIGN, HAVE WITNESSED, AND RETURN THE HEALTH RECORD FORM AND THE CHILD SAFETY POLICY AND RELEASE, ALONG WITH YOUR COMPLETED REGISTRATION FORM.
Return the forms to the registrar.
PLEASE PRINT AND COMPLETE:
Athlete’s Name_____________________________ Birth Date: (dd/mm/yyyy)________________ Age__________
Address__________________________________________ Phone_________________________Sex_____________
City/Town______________________________________ Province______ _______Postal Code__________________
Sport Camp Chosen and Date of Session______________________________________________________________
Name of Parent/Guardian__________________________________ Address__________________________________
Telephone Numbers - Home ___________________Business___________________ Cell________________________
Telephone numbers where parent/guardian can be reached while athlete is attending camp:
________________________________________________________________________________________________
Medical Number_______________________________________________________________________
Blue Cross or other Number _________________________________________
Has your son/daughter been immunized? Yes _________ No_______
Is your son’s/daughter’s immunization up to date? Yes _______ No_______
Recent Illness, injury and/or Operations:(within the last year)
_______________________________________________________________________________________________
(include infectious diseases, colds,flu,etc.)
Special Conditions (Specify as to activity for asthma, allergies, joint weaknesses etc.)
_______________________________________________________________________________________________
List all medications used at present and during the last 6 months that you will be bringing to Camp.
________________________________________________________________________________________________
List all injuries for the past year (strains, broken bones, head injuries etc.)
________________________________________________________________________________________________
N.B. NATIONAL HEAD INJURY PROTOCOL APPLIES
I understand that the information on this form, and other medical information I may subsequently provide, is being collected because the nature of the camp environment is such that illness and/or injury could occur to the athlete, and that the athlete may, therefore, require first aid or other medical treatment. The information collected on this form will be used and disclosed only in the event of a medical emergency, illness or injury to the above named athlete, and will otherwise be kept private and confidential. I understand that in the normal course, this form will be received and read by the Legion Athletic Camp First Aid Director and First Aid Staff only.
I understand that, upon review of the medical form, the First Aid Director and/or First Aid Staff may advise the Head Coach of the athlete's respective sport as to any particular condition that may be relevant to the athlete's participation in his or her respective sport, in order to ensure the safety of the athlete.
I believe the above athlete to be fit, and so far as can be determined, he/she is in good health, is not suffering from any illness and is physically and mentally able to participate in demanding Camp athletic activities. I give permission for care of any minor injuries requiring local anesthetic (lacerations, cuts, etc.) administered by a physician.
I am aware that the nearest medical facility is 30 minutes from the Camp.
Due to general public access within the IPG we cannot guarantee an allergy free environment.
If Epipens are needed 3 Epipens are required for the safety of your child due to the distance from the nearest medical facility.
I consent to the disclosure of the information contained on this form, and other medical information I may subsequently provide, to medical professionals in the event of a medical emergency, illness or injury to the above named athlete.
I understand that the medical forms will be retained, in a private and confidential manner, for a period of one (1) year, and then destroyed.
I certify that I have read this form and that the information contained on this form is true and correct. I understand that it is my responsibility to inform the Camp if the athlete's medical situation changes and the information on this form needs to be updated or amended. I will indemnify and hold harmless The Royal Canadian Legion Sports Foundation Inc. (Legion Athletic Camp), its successors and assigns, for any and all liability, injury, loss or damage (including injury, loss or damage resulting in death), however caused, that results out of my failure to inform the Camp of the above named athlete's medical conditions, illnesses or injuries.
I certify that I have also read and signed the Child Safety Policy and Release, and I understand that this form is to be read together with the Child Safety Policy and Release.
Date _________________________________________________
Parent/Guardian (Signature)______________________________________________________________________
Witness _______________________________________________________________________________________