Medical Information Form

Please answer ALL questions (it will not let you submit an incomplete form). If something does not apply to you please use N/A.

Personal Information

Email address *

First name *

Last name *

Varsity Sport *

Contact Information

Street Address *

City *

Province/State *

Country *

Postal Code *

Phone Number *

Emergency Contact

Name *

Relationship *

Phone *

Health Information

Health Card Number *

Family Doctor Name *

Family Doctor Phone Number *

Health History

Any allergies to drugs? *

Yes No

If yes, please specify any drug allergies *

Any allergies to food? *

If yes, please specify any food allergies *

Any dietary restrictions? *

If yes, please specify any dietary restrictions *

Any other allergies? *

If yes, please specify any other allergies *

Any permanent disabilities? *

If yes, please specify any permanent disabilities *

Are there any regular medications that you take? *

If yes, please list all medications you take regularly *

Is there any other information we should know about your medical history? *

If yes, please provide further details regarding your medical history *

* required field