What’s FUTSAL?

ArticlesPosted on 22 de November de 201927 de November de 2019

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Player First Name

Player Last Name

Player Date of birth

Gender

Uniform Size

Age Group

Is there any information you would like us to know about the person you are registering (allergies, traumatic brain injury or jolt to the head)?

Has the player ever recievid medical attention for traumatic brain injury?

Check any symptoms this player has experienced after jolt/bump to the head or body

Headache or Pressure in Head
Nausea or Vomiting
Balance Problems or Dizziness
Blurry or Double Vision
Sensitivity to Light or Noise
Feeling Sluggish or Foggy
Confusion or Concentration/Memory Problems
Feeling Down or Just Not Right

Parent / Guardian First Name

Parent / Guardian Last Name

Parent / Guardian Email

Parent / Guardian Phone Number 1

Parent / Guardian Phone Number 2

Street Address

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Postal Code

In case we can’t reach the parents/guardians, would you like to let the information of someone else?

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

Emergency Contact Relationship to Participant

Insurance Company Name

Insurance Policy Number

Physician’s Name

Physician’s Adress

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