Hockey Boot Camps

MEDICAL HISTORY RECORD

Player__________________________ Age_______ Date of Birth___________ Phone__________________

Address________________________________________________________ Postal Code______________

Parents Name________________________________ Phone (Bus)______________ (Res.)______________

Medical Insurance Number______________________________ Family Dr.____________________________

Significant Medical Conditions (e.g., epilepsy, diabetes, orthopedic problems, dangerous allergies)

______________________________________________________________________________________

______________________________________________________________________________________

Last tetanus booster (check one) Less than 3 years______ 3 - 5 years______ More than 5 years______

Parent's Signature_____________________________________ Date___________________________

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PERSONAL INFORMATION

PREFERRED HOCKEY POSITION_______________ SECOND PREFERRED POSITION_______________ SHOOTS: Lor R

HEIGHT__________ WEIGHT__________ D.O.B.__________ POSITION PLAYED LAST YEAR_________________

TEAM LAST YEAR____________________ LEVEL of COMPETITION_______________ DIVISION______________

ASSOCIATION_______________________ PROVINCE________ COACH______________ PHONE____________

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Goalie $200.00 - Players $275.00

Mail to: Hockey Boot Camps, 3557 Keeling Place, RR2, Cobble Hill, B.C., VOR 1L0

Phone: (250) 743-4765