Athlete Medical Form - Special Olympics British Columbia printable pdf download

Special Olympics Burnaby Local 4B

Paid Cash____ Chq # ____

2016 – 2017 Athlete Medical Form

Initial ______

Athlete Name: __________________________________________________________

Phone: _________________________

Address: _______________________________________________________________

Cell:

_________________________

City: ____________________________________

Postal Code: _________________

CCYY / MM / DD

Birth Date:

E Mail Address: __________________________________________________________

Sex:  M  F

Sport Participation:

 5 Pin Bowling

 Aquatics (Swimming)

 Cross-Country Skiing

 FUNdamentals

 Snowshoeing

 10 Pin Bowling

 Athletics (Track & Field)

 Curling

 Golf

 Soccer

 Active Start

 Basketball

 Club Fit (Fitness)

 Powerlifting

 Softball

 Alpine Skiing

 Bocce

 Floor Hockey

 Rhythmic Gym

Medical Information and History:

Doctor: _________________________________ Phone: ____________________ B.C. Care Card #: ________________________

Down Syndrome:  Yes  No

If Yes Atlanto-Axial X-ray Date: _____________________________  Positive  Negative

Seizures:  Yes  No If Yes Type: _______________________________________ Frequency: ___________________________

Treatment: __________________________________________________________________________________________________

Diabetic:  Yes  No If yes treatment:  Diet  Pill  Injection Schedule: __________________________________________

Tetanus Shot:  Yes (within  5 yrs  10 yrs)

Asthma:  Yes

Cerebral Palsy:  Yes

Heart Condition:  Yes

 No

Other (please detail): __________________________________________________________________________________________

Allergies:  Food ____________________________________________________________________________________________

 Drugs ____________________________________________  Other _______________________________________

Does the Athlete have or use any of the following:

 Glasses

 Hearing Aids

 Dentures

 Contact Lenses

 Other ______________________________________

Other Info: _________________________________________________________________________________________________

Self Administered:  Yes  No (must be updated prior to any trips)

Medication:

Name & Dosage __________________________________________________________________________________ Time ___________________

Emergency Contacts:

Contact 1: ___________________________________________

Contact 2: ____________________________________________

Email:

Email: _______________________________________________

Home Phone: ________________ Cell: _____ _____________ Home Phone:________________ Cell: ____________________

Relation:  Parent  Guardian  Caregiver  Other ______________ Relation:  Parent  Guardian  Caregiver  Other______________

I acknowledge that all the information given on this form is correct to the best of my knowledge and that I will update this information if it changes.

_____________________________________________________________

____________________________________

____________________

Signature of Athlete / Parent / Guardian (circle one)

Name of Person Completing this Form

Date

General Release; By signing below you acknowledge and give permission to Special Olympics BC – Burnaby to use pictures and / or other electronic images of yourself

for the purposes of promotional materials that the organization may utilize but not limited to printed material, web sites and videos/CDs

_____________________________________________________________

Special Olympics Burnaby values the privacy of its athletes and

Signature of Athlete / Parent / Guardian (circle one)

as such protects the confidentiality of your personal information