Speed Skating Manitoba - SSM Development Team Application

SSM Development Team Application

Respondent

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First name *

Last name *

Email *

Mobile

Athlete Information

Athlete Name: *

Athlete Date of Birth: *

Athlete's Club Affiliation: *

Central Eastman Interlake Shilo Westman Winnipeg Central Winnipeg Club

Athlete's Speed Skating Canada Number: *

Provincial Health Number (6 digit): *

Provincial Health Number (9 digit): *

Parent/Guardian names: *

Parent/Guardian emails: *

Athlete email: *

Emergency Contact (if unable to reach parent or guardian). Include name, email and phone number: *

Do you have any allergies or medical conditions? *

No Yes

List allergies or medical conditions. *

Do you wear contact lenses? *

No Yes

Have you ever had surgery? *

No Yes

Please specify: *

Have you had previous injuries requiring restriction of activity? *

No Yes

Please specify: *

Name of athlete's physician: *

Phone number of athlete's physician: *

Medical Release

I attest that I/my child /my ward am/is medically fit to participate in speed skating activities. Experience has shown that in connection with speed skating activities, illness or accident may occur, and immediate surgical or medical attention may be necessary. This is my permission for the official in charge, or his/her deputy, or the event doctor to make the necessary medical arrangements for me/my child/my ward in the event of an emergency. Surgery will not be conducted unless, life threatening, without consent of parent or guardian. I understand that the next of kin will be notified by the quickest possible means if this authority is exercised.

Do you consent to the medical release above? *

I consent I do not consent