Willowdale Sports Club

PO Box 543, 3299 Bayview Avenue, Toronto, Ontario M2K 2Y5

Medical Information

First Name: ____________________   Last Name: ________________________________

Please circle Yes or No:

  Yes   No   Previous Concussions   Yes   No   Hearing problem
  Yes   No   Fainting episodes during exercise   Yes   No   Asthma
  Yes   No   Epileptic   Yes   No   Trouble breathing during exercise
  Yes   No   Wears glasses   Yes   No   Heart condition
  Yes   No   Are lenses shatterproof?   Yes   No   Diabetic
  Yes   No   Wears contact lenses   Yes   No   Illness lasting more than week in last year
  Yes   No   Wears dental appliance   Yes   No   Allergies

Medication required: ____________________________________________

Medical condition requiring attention:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Signature of
Parent or Guardian: ___________________________________  Date:___________________