Waiver Form | Drive Hockey Development

Full Name *

Date of Birth *

Address *

Email *

Parent/Guardian Full Name *

Parent/Guardian Phone Number *

Secondary Parent/Guardian Full Name

Secondary Parent/Guardian Phone Number

Medical History *

Previous history of concussions
Fainting episodes during exercise
Epileptic
Wears glasses
Lenses are shatterproof
Wears contact lenses
Wears dental appliance
Hearing problem
Asthma
Trouble breathing during exercise
Heart condition
Takes medication
Allergies
Health problem that would interfere with hockey participation Illness lasting more than a week requiring medical attention in past year
Injuries requiring medical attention in past year
Admitted to hospital in last year
Surgery in last year
Hepatitis B vaccination
Diabetic
Wears medical information bracelet/necklace
Presently injured
Vaccinations up to date

Please provide details for any boxes checked above or any medical information not listed: *

Medical Authorization & Consent

I understand that it is my responsibility to keep the team Safety Person advised of any change in the above information as soon as possible.

In the event of a medical emergency and that no one can be contacted, team management may arrange for my child to be taken to a hospital or physician if deemed necessary.

I hereby authorize the physician and nursing staff to undertake examination, investigation, and necessary treatment of my child.

I also authorize the release of medical information to appropriate personnel (coach, physician) as deemed necessary.

I agree to the above medical authorization and consent. *

Full Name to Sign *

Information

Official Partners: