MEDICAL INFORMATION FORM< All TopicsPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. – Step 1 of 5 DISCLAIMER By completing the form below, you are agreeing to disclose personal/medical information about your child. Please ensure all information is accurate. All information collected in this form, will be kept safe and not used for any other purpose other than the associated program PLAYER NAME AND INFORMATION *FirstLastAddress *Address Line 1CityState / Province / RegionPostal CodeNextLEGAL GUARDIAN 1 INFORMATION *FirstLastLEGAL GUARDIAN 1 PHONE NUMBER *LEGAL GUARDIAN 2 INFORMATION *FirstLastLEGAL GUARDIAN 2 PHONE NUMBER *NextName of emergency contact if legal guardian is not available/reachable *FirstLastEmergency Contact Phone Number *Relationship to Athlete *Name of Family Doctor *FirstLastFamily Doctor Phone Number *NextPRE-EXISTING HEALTH CONDITIONS – (Please check all that apply)AsthmaInhalerAllergies – Food or otherHearing issuesDiabeticTaking medication for permanent health conditionsEpi-Pen / AllerjectHeart ConditionEpilepticBlood DisordersHistory of ConcussionsMedical Alert Bracelet/NecklacePrescription eyewearPermanent physical injuryDepression/Mood DisorderHospitalized in the last yearPlease provide details on any checked items from above and/or information about any conditions not included above. Please indicate any and all allergies or medications:Next DISCLAIMER Recognizing the possibility of physical injury associated with soccer and in consideration for BRAMPTON ELITE SOCCER ACADEMY accepting the registrant for its soccer programs and activities (the “Programs”), I hereby release, discharge and/or otherwise indemnify the BRAMPTON ELITE SOCCER ACADEMY, its affiliated organizations and sponsors, their employees and associated personnel, including the owner of fields and facilities utilized for the Programs against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize. My son/daughter has received a physical examination by a physician and has been found physically capable of participating in the Programs. I hereby give my consent to have an athletic trainer and/or doctor of medicine or dentistry provide my son/daughter with medical assistance and/or treatment and agree to be responsible financially for the cost of each assistance and/or treatment. I understand that it is my responsibility to advise the Team Management and BRAMPTON ELITE SOCCER ACADEMY immediately if there is a change in any of the above information. In the event of a medical emergency, Team Management has permission to provide immediate First Aid as required and to take or have my child taken by EMS to hospital if deemed necessary. I hereby authorize the physician and nursing staff of the medical institution to which my child is taken to undertake examination investigation and necessary treatment of my child. I authorize the information on this form to be released to appropriate parties (physician, nurse, coach) as deemed necessary. Refusal to Complete Medical Information Form (check only if the above information has not been completed) I understand that by refusing to provide the information requested on this form I am releasing Brampton Elite Soccer Academy of any liability or medical claims resulting from this decision (signature required below) CheckboxesBY CHECKING THE BOX AND ENTERING MY NAME BELOW, I CERTIFY THAT I UNDERSTAND AND AGREE TO THE ABOVE STATEMENTName *FirstLastDate / TimeDateTimeHealth Card Number *Requirement in case of emergenciesSubmit