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MANITOBA SOCCER ASSOCIATION
PROVINCIAL PROGRAM
MEDICAL FORM
Last Name_____________________________ First Name_____________________________ Home Phone ____________________ Address ______________________________________________ Postal Code _____________ Sex: Male _______ Female _______ MHSC Nos. ___________________ ___________________ Blood Type: ____________ Contact Lenses: Yes ___ No ___ Personal Health Plan _________________________________ Policy No. ___________________ Additional Health Plan _______________________________ Policy No. ___________________ Medical conditions/physical limitations__________________________________________________________________________
Allergies ____________________________________ Medications _______________________________________________
Food allergies / preferences ___________________________________________________________________________________
Family Physician _________________________________________________________ Phone _____________________________ Family Dentist ___________________________________________________________ Phone _____________________________ ____________________________________________________________________________________________________________
Father’s / Guardian’s Name ________________________________________ E-Mail ______________________________________ Work Phone _________________________ Home Phone _________________________ Cell Phone _________________________ Mother’s / Guardian’s Name _______________________________________ E-Mail ______________________________________ Work Phone _________________________ Home Phone _________________________ Cell Phone _________________________ If not available in an Emergency, additional persons to Notify: 1. Name ______________________________ Relationship to player _____________________ Phone _____________________ 2. Name ______________________________ Relationship to player _____________________ Phone _____________________ MANITOBA SOCCER ASSOCIATION
PROVINCIAL PROGRAM
AUTHORIZATION FOR NON-PRESCRIPTION DRUGS

As the parent/guardian of ________________________________ I authorize the following non-prescription medications to be
(Child’s Name)
administered by the Therapist, a member of the Coaching Staff or Medical Personnel on an “as required” basis.
Please place your initials where you give consent.


AUTHORIZATION FOR SELF-ADMINISTRATION OF MEDICATION
As the parent/guardian of ________________________________ I authorize the following medications to be self-administered by my
child on an “as required” basis.
Please place your initials where you give consent.

All medications and be responsible for their medication All medications and staff be responsible for their medication _____ Other ______________________________________
I, the undersigned, being the parents/guardians of ____________________________________ do hereby give permission for him /her
(child’s name)
to travel and participate in activities associated with the Provincial Soccer Program. I acknowledge all risks and hazards incidental
to such participation including transportation to and from all activities. In case of serious accident or illness, I give my permission to
any Medical Personnel, Dentist or Therapist to render emergency medical, surgical, or dental treatment that the medical personnel,
Dentist or Therapist may deem necessary, subject to the following restrictions: ___________________________________________
___________________________________________________________________________________________________________
Signature of Parent / Guardian ___________________________________________________ Date ______________________ Signature of Parent / Guardian ___________________________________________________ Date ______________________

Source: http://www.manitobasoccer.ca/documents/medicalform.pdf