HEALTH & MEDICAL FORM | Immaculate Heart CYO

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Basketball Net

HEALTH AND MEDICAL INFORMATION

Thank you for registering. Please be sure to fill out the information below.

Player's First Name

Player's Last Name

Family Physician Name

Family Physician Number

Physician's Street Address

Physician's City

Physician's State

Physician's Zip code

Medical Plan

Medical Plan Number

Do you authorize the adult leader to authorize mdeical treatment for your child in an emergency, as considered necessary by the attending physician?

Yes

No

If No, please state reasons why you do not want medical care given to your child in an emergency:

List all conditions (such as allergies, seizures, etc) for which your child requires ongoing medication and state the type of medication given:

Has your child had difficulty with the following (check all that apply):

Asthma

Faiting Spells

Convulsions

Diabetes

Heart

Eyes

Nose

Throat

Lungs

Digestion

Menstrual Problems

Other

If Other, please list

List any physical restriction or restriction for any sport activity on the basis of medical condition:

State the date of your child's last physical examination:

IT IS STRONGLY RECOMMENDED THAT EACH CHILD HAVE A PHYSCAL EXAMINATION PRIOR TO PARTICIPATION IN ANY SPORTS ACTIVITY.

Thanks for submitting!

© 2023 Immaculate Heart of Mary Catholic Youth Organization

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