Player Medical Information Form

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THIS FORM MUST BE AVAILABLE AT ALL BASKETBALL ACTIVITIES

Player Medical Information Form


(must be completed by parent or guardian)

Players Name: __________________________________________________________________________


Parent/Guardians Name: ____________________________________________ Phone: _______________
Address: _________________________________________________________ Work Phone: __________
Cell Phone: ___________
Person, other than parent, to notify in case of emergency:
Name: ___________________________________________________________ Phone: _______________
Cell Phone: ___________
Family Physician: __________________________________________________ Phone:
Address: _________________________________________________________
Medical Insurance: _________________________________ Policy #: ____________________________
Hospital Preference: ______________________________________________________________________

The player has or is subject to (check if yes):


Asthma Fainting Spells Convulsions Diabetes Arthritis
Heart Trouble Allergy or Reaction to ANY Medication, Insect Bites/Stings, Food
Sports Restrictions (please list):
Other (please describe):
Difficulty with (check if yes):
Eyes, Ears, Nose, Throat Digestion Menstrual Problems Lungs
Any condition now requiring medication? Name of Medication: ______________________________
Reason for medication: ___________________________________________________________________
Any restriction of activity for medical reasons?
Explain: _______________________________________________________________________________
_______________________________________________________________________________________

Signature of Parent/Guardian: ______________________________________ Date: ________________

Signature of Player: _______________________________________________ Date: ________________

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