Player Medical Information Sheet

Keep each player's medical and emergency details on hand for your club or league. Parents provide contacts, doctor and dentist, health conditions, vaccinations, medications and allergies, then sign the authorizations.

Use this template

In the Claude connectors directory

Page 1

Program Information

Instructions

Player Name

First Name

Last Name

Date of Birth

Address

Street Address

City

State / Province

ZIP / Postal Code

Home Phone

Cell Phone

Provincial Health Care Number

Page 2

Mother's Name

First Name

Last Name

Father's Name

First Name

Last Name

Mother's Work Phone

Father's Work Phone

Alternate Emergency Contact (if parents are unavailable)

First Name

Last Name

Emergency Contact Phone

Emergency Contact Address

Street Address

City

State / Province

ZIP / Postal Code

Page 3

Doctor's Name

Doctor's Phone Number

Dentist's Name

Dentist's Phone Number

Medical Details

Date of last physical examination

Page 4

Diabetic

Yes No

If yes, which type?

Wears a medical ID bracelet or necklace?

Yes No

If yes, for what purpose?

Currently injured?

Yes No

If yes, which body part?

Vaccinations up to date?

Yes No

Date of last tetanus shot

Details for any "Yes" answers

Page 5

Medications

Allergies

Recent Injuries

Other relevant information

I authorize emergency medical treatment if I cannot be reached

I agree I do not agree

I consent to sharing this information with coaches and staff

I agree I do not agree

I confirm that the information provided is accurate

I agree I do not agree

Date

Parent or Guardian Signature

Sign here

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