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Player First Name
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Player Date of birth
Gender
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Age Group ---- Select One ---- U11 and under (birth years 2009, 2010, 2011, 2012) U14 (birth years 2006, 2007, 2008)
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
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Parent / Guardian Phone Number 1
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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
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