Emergency Contact Information U-17 Boys
This form is so that we can have a digital record of emergency contacts and information to help us better serve the players and family. None of this information will be shared with anyone aside from coaches to use on an emergency basis (primarily, this will occur for practices/trips where the parents are not in attendance). There may be some repeat questions from other forms; however, this helps us keep all the information in one place. 
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Full name of Player: *
Care Card/PHN *
Birth Date of Player *
Family Doctor *
Doctors phone number *
Doctors phone number *
Name of Parent/Guardian 1 *
Phone Number of Parent/Guardian 1 *
Email of Parent/Guardian 1 *
Phone Number of Parent/Guardian 2
Email of Parent/Guardian 2
Home Address of Player *
Beyond normal occurrences, player is potentially subject to (elaborate more in the following question): *
Required
Please note any health problems, physical handicap, emotional difficulty, behaviour problem, or other factors that may limit participation with Shuswap VC. *

Has the student had a previous injury that would require special first aid treatment should another injury occur?

 *

Emergency Contact 1 Name

 *

Emergency Contact 1 Phone Number

 *

Emergency Contact 1 Email

 *

Emergency Contact 2 Name

Emergency Contact 2 Phone Number

Emergency Contact 2 Email

I certify that to the best of my knowledge, the information supplied on this form provides a full and accurate account of the required medical information about the above named player.  I certify that the state of health of the above named student is such that he/she can undertake the Shuswap VC season within any restrictions supplied on this form.  I will empower the chaperones to authorize any emergency treatment required to the above named student until such time as contact has been made with his/her parents or guardians.

Please Record your name (which guardian) in the "other" line.

 *
Required
Social Media Agreement. Please indicate whether you are okay with your child appearing in social media posts (instragram/facebook), or even on our website.  *
Required
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