VOLUNTEER’S NAME:
DATE OF BIRTH:	/	/
DD	/	MM	/	YYYY
Do you or your Parents, if on their insurance, have benefits through their employer? (please note employer benefits are primary)	YES	NO

MEDICAL HISTORY:
Have you ever had any of the following? Please put an “X” in the corresponding boxes below
Y	N	Y	N	Y	N	Y	N
Arthritis	Chronic Indigestion	Enlarged Liver/Spleen	Gastrointestinal Issue
Chronic Migraines	Chronic Headaches	Hernia-Abdom/Inguinal	Joint Conditions
Epilepsy convulsive	Kidney Stones	Tumors/Growths/Cysts	Bone Condition
Asthma	Rheumatic Fever	Anxiety Attacks	Chicken Pox
Hay Fever or Sinus	Heart Disease/Murmur	Frequent Colds	Scarlett Fever
Other Allergies	High Blood Pressure	Motion/Car Sickness	Pneumonia
Eye Difficulties	Tuberculosis	Ear/Nose Problems	Hepatitis
Respiratory Problem	Diabetes	Throat Problems	Appendicitis
Frequent Bronchitis	Mononucleosis	Chest Tightness	Shortness of Breath
Chronic Illness	Kidney Disease	Jaundice
If YES to any of the above, please give details:
Do you wear:	Glasses	Contacts	Both	N/A	Are they worn during athletic participation?	Yes	No
Please describe any other serious illness, hospitalizations, injuries, deformities not listed above:

ALLERGIES: Please put an “X” in the corresponding boxes below
Y	N	Y	N	Y	N	Y	N
Bee Stings	Aspirin	Grass or Ragweed	Penicillin
Iodine or Similar	Sulfa Drugs	Latex Allergies	Anti-inflammatory
Please list any food or other allergies not mentioned above:
Have you ever suffered from a fracture or dislocation?	Yes	No	If yes, please explain:
Any medical conditions which will interfere with athletic participation?	Yes	No	If yes, please explain:
Are you currently on any medications, either prescription or over the counter?	Yes	No	If yes, please explain:
Concussion History:
Have you suffered a concussion?	Yes	No	If yes, how many?
Did you ever have a loss of consciousness due to a concussion?	Yes	No	If yes, how long?
Have you ever been hospitalized for concussion?	Yes	No	If yes, how long?
How long were you out/not playing after your last concussion?
EMERGENCY CONTACT:
Name:	Relationship:	Telephone:
I understand that it is my responsibility to keep the team management advised of any change in the above information as soon as possible and that in the event no one can be contacted, team management will take myself/ my child to the hospital/M.D. if deemed necessary. I hereby authorize the physician and nursing staff to undertake examination, investigation, and necessary treatment of myself/ my child. I also authorize release of information to appropriate people (coach, physician etc.) as deemed necessary.
Signature of Volunteer OR Parent/ Guardian, if under 18:	Date: