This 3 sentence summary provides the key details from the player medical information form:
The form collects medical information and emergency contact details for basketball players, including any medical conditions, restrictions, medications, insurance information and signatures of the parent/guardian and player. Parents are asked to disclose any asthma, fainting spells, convulsions, diabetes, arthritis, allergies, heart trouble or other conditions the player has that may be relevant along with any difficulty seeing, hearing, breathing or menstrual problems.
This 3 sentence summary provides the key details from the player medical information form:
The form collects medical information and emergency contact details for basketball players, including any medical conditions, restrictions, medications, insurance information and signatures of the parent/guardian and player. Parents are asked to disclose any asthma, fainting spells, convulsions, diabetes, arthritis, allergies, heart trouble or other conditions the player has that may be relevant along with any difficulty seeing, hearing, breathing or menstrual problems.
This 3 sentence summary provides the key details from the player medical information form:
The form collects medical information and emergency contact details for basketball players, including any medical conditions, restrictions, medications, insurance information and signatures of the parent/guardian and player. Parents are asked to disclose any asthma, fainting spells, convulsions, diabetes, arthritis, allergies, heart trouble or other conditions the player has that may be relevant along with any difficulty seeing, hearing, breathing or menstrual problems.
This 3 sentence summary provides the key details from the player medical information form:
The form collects medical information and emergency contact details for basketball players, including any medical conditions, restrictions, medications, insurance information and signatures of the parent/guardian and player. Parents are asked to disclose any asthma, fainting spells, convulsions, diabetes, arthritis, allergies, heart trouble or other conditions the player has that may be relevant along with any difficulty seeing, hearing, breathing or menstrual problems.
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: ________________