Great Western Lacrosse Camp
P A R E N T ’ S M E D I C A L S T A T E M E N T
Player’s Name____________________________ Birth Date__________ M__ F__
In case of injury, I hereby give consent for my child to have initial first aid administered by qualified personnel in charge and to be transported to a Physician or Hospital for further treatment if it deemed necessary. I also give my permission for my child to be treated by Hospital personnel in the event he/she is injured at the Camp and in need of medical attention.
BRIEF MEDICAL HISTORY
( l e a v e n o t h i n g b l a n k )1. HAS HAD INJURIES REQUIRING MEDICAL TREATMENT: YES___ NO___
2. HAS HAD AN ILLNESS REQUIRING HOSPITALIZATION: YES___ NO___
3. IS CURRENTLY UNDER A PHYSICIAN’S CARE: YES___ NO___
4. TAKES MEDICATION OR USES AN INHALER:
YES___ NO___
5. IS HEARING IMPAIRED OR WEARS GLASSES / CONTACT LENS: YES___ NO___
6. HAS FIXED OR REMOVABLE APPLIANCES IN MOUTH:
YES___ NO___
7. THERE IS A REASON FOR THIS PERSON TO AVOID CONTACT: YES___ NO___
8. HAS FAINTED DURING EXERCISE OR LACROSSE ACTIVITIES: YES___ NO___
9. HAS A HISTORY OF HEART DISEASE OR DIABETES IN THE FAMILY: YES___ NO___
10. HAS ANY TYPE OF PHYSICAL LIMITATION:
YES___ NO___
All "YES" responses MUST be explained:_______________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
My child is allergic or has a sensitivity to the following:
(bees, milk, medications, etc.)Please list any medical conditions about your child that would be helpful to a
physician:
_________________________________________________________________________
Print Parent’s Name_____________________________________ Date______________
Parent’s Signature_________________________________________________________
(leave the next question blank if you have no preference)