Program of Excellence Registration

Player Profile Form

E-MAIL IS OUR PRIMARY METHOD OF COMMUNICATION. PLEASE LIST ACTIVE E-MAIL ADDRESSES:
Program:
Hockey MB Region:
Full Name:
Address:
City/Town:
Province:	MB Postal Code:
Home Phone:
Birthday:	/ /
Sex:
Mother's Name:
Father's Name:
Alternate Phone #s:

Player's E-mail:
Mother's E-mail:
Father's E-mail:
PERSON TO CONTACT IN CASE OF EMERGENCY, IF PARENTS UNAVAILABLE:
Name/Relationship:
Emergency Phone:
Emergency Cell:
Doctor's Name:
Doctor's Phone:
Dentist Name:
Dentist's Phone:
Provincial Health #:
Shot:
Height:	Weight:
Position:
Current Team Name:
Category:
Division:
Coach:
Coach's Phone:
Coach's Cell:
PLEASE SELECT THE APPROPRIATE RESPONSE BELOW:
Yes No	Previous history of concussions
Yes No	Epileptic
Yes No	Fainting episodes during exercise
Yes No	Wears Glasses
Yes No	Are lenses shatterproof?
Yes No	Wears Contact Lenses
Yes No	Wears dental appliance
Yes No	Hearing problem
Yes No	Trouble breathing during exercise
Yes No	Asthma
Yes No	Heart Condition
Yes No	Diabetic
Yes No	Has had an illness lasting more than a week in last year
Yes No	Has had injuries requiring medical attention in last year
Yes No	Wears Medical Alert ID
Yes No	Allergies
Yes No	Surgery in the last year
Yes No	Medication
Yes No	Has been hospitalized in last year
Yes No	Presently injured
PLEASE GIVE DETAILS IF YOU ANSWERED YES TO ANY OF THE ABOVE ITEMS:

Last Tetanus Shot:	/ / (mm/dd/yyyy)
Last Complete Exam:	/ / (mm/dd/yyyy)
APPAREL SIZING INFORMATION:
T-Shirt Size:
Shorts Size:
Jacket Size:
ANY MEDICAL CONDITION OR INJURY SHOULD BE CHECKED BY YOUR PHYSICIAN BEFORE PARTICIPATING IN A HOCKEY PROGRAM.
** all fields are required