London Beefeater Football Club

London Beefeater Football Club

Website:

E-Mail:

INFORMATION FORM—2015

(Print Neatly if filling in manually)

NAME

/ DATE OF BIRTH

(mm/dd/yyyy)

PLACE OF BIRTH

(FIRST YEAR CJFL PLAYERS MUST PROVIDE A PHOTOCOPY OF BIRTH CERTIFICATE (with another piece of Photo ID) OR PASSPORT ID PAGE OR PERMANENT RESIDENCY DOCUMENT)

HEALTH CARD #

/ (Include version code)
ADDRESS

(Number, Street, City, Postal Code)

PERMANENT ADDRESS

(If different from above)

PHONE

/ HOME: / CELL: / WORK:
E-MAIL ADDRESS
HEIGHT / WEIGHT / POSITION(S)

HIGH SCHOOL ATTENDED

/ COACH / YEARS
COMMUNITY FOOTBALL EXPERIENCE
OFC/OVFL/OTHER / COACH / YEARS
PREVIOUS CJFL OR CIS EXPERIENCE / COACH / YEARS

EMERGENCY CONTACT

NAME / RELATIONSHIP / HOME PHONE / CELL PHONE / WORK PHONE

NAME:

DOCTOR’S NAME: PHONE:

CIRCLE/HIGHLIGHT THE APPROPRIATE RESPONSES – Supply necessary details (Highlight your answers)
History of concussion - / YES / NO
History of epilepsy - / YES / NO
Glasses - / YES / NO
● Shatter proof lenses / YES / NO
● Contact lenses / YES / NO
Dental appliance / YES / NO
Hearing problem / YES / NO
History of asthma or exercise-induced asthma / YES / NO
Dizziness or fainting during exercise / YES / NO
History of heart condition / YES / NO
● Heart murmur / YES / NO
● Other / YES / NO
High blood pressure / YES / NO
Diabetes / YES / NO
Mononucleosis / YES / NO
Illness lasting more than 1 week / YES / NO
Hospitalized / YES / NO
Physical within last six months / YES / NO
Year of last tetanus shot

Muscular-Skeletal History – list all injuries and treatment/surgery

Injury(R/L) / Year / Doctor / Treatment / Related Problems

Are you aware of any family medical history that is relevant that might prevent you

from playing football?YESNO (Highlight one)

If yes, please provide details:

MEDICATIONS

Prescription medications / Over-the-counter medications

If you have listed any medications you MUST read the Canadian Centre for Ethics information at . If the medications are restricted, the Therapeutic Use Exemption Application form or, if applicable, the Abbreviated Therapeutic Use Exemption Form MUST be completed, signed by your physician and returned to the club. Ask the team for the appropriate form if it is necessary.

Any medical condition or injury should be checked by a physician prior to participating in athletics.

I understand that it is my responsibility to keep the medical staff advised of any changesin the above information as soon as possible.

I understand that any medical information relevant to my participation may be discussed with the appropriate personnel (i.e. team trainers, physicians and coaches.) I understand that football is a collision sport and thus has some inherent risk of injury.

I have provided factual and complete information to the best of my ability and I have read the above statements prior to signing this document.

Player Signature: ______Date: ______

(To be signed at Beefeater workout/practice)