Fort Langley Canoe Club Personal Health Form

Name of Athlete                                                                     

Care Card Personal Health No.                                                  Date of Birth                                        

Family Doctor                                                                            Phone                                                  

Name of Parent/Guardian                                                        

Address                                                                                  

Home Phone                                                                             Business Phone                                    

In case of emergency contact Parents/or

Name                                                                                        Phone                                                  

Please note any health problems, physical handicap, emotional difficulty, behaviour problem, or other factors which may limit full participation in this program.  Use back of sheet if necessary.

Has the athlete had a previous injury which would require special first aid treatment should another injury occur?    Explain                                                                                                                                                             

The athlete has received the regular immunization program administered in B.C. for diphtheria, pertusis & tetanus (DPT; tetanus and diphtheria (Td); polio; measles, mumps & rubella (MMR).  

Yes      No     (circle.) If no, please explain                                                                                            

Contact Lenses: Yes    No   (circle)

Child is subject to

(     ) asthma                 (     ) ear ache               (     ) fainting              (     ) high blood pressure

(     ) eye infection         (     ) sensitive skin        (     ) seizures             (     ) motion sickness

(     ) bronchitis              (     ) nosebleeds            (     ) headache           (     ) dizziness                                         

(     ) kidney problems    (     ) pulled muscles      (     ) sprains              (     ) dislocations                                     

(     ) severe allergies (describe below)               (     ) other (describe below)

Medications:  All medicines should be clearly labeled with the child's name and the information below. All medications must be controlled and in the possession of the first aid attendant (except for allergies).   Use back of form if additional space is needed to list medications.

Name of medicine                                                                  Used for                                               

To be administered by                                                               Quantity & times                                   

Permission granted by_______________________________ Given how