Our mission is to provide young athletes an opportunity to learn, participate and compete within a structured league environment. Our staff is committed to developing character, teamwork and respect for the game through a high level of coaching and instru

SAN DIEGO COUNTY LACROSSE ASSOCIATION

                          MEDICAL FORM

(To be completed by parent or guardian)

ATHLETE’S NAME: ___________________________________

In case of injury, I hereby give consent for my son/daughter to have initial first aid administered by team personnel in charge and to be transported to a doctor for further treatment if deemed necessary.

Home Phone ____________________________ Work Phone __________________________

Family Doctor ____________________________ Doctor phone _________________________

Medical Insurance Carrier ________________________Policy Number ____________________

Covered Employee if group health insurance: ___________________________

Brief Medical History:

Please circle the appropriate response for all of the following questions regarding your son/daughter’s medical history:

Yes No    Has had injuries requiring medical attention

Yes No    Has had an illness requiring hospitalization

Yes No    Is under a physician’s care at this time

Yes No    Is allergic to something (i.e. medications, bee stings, milk, etc…). Please list

Yes No    Takes medication at this time. Please list.

Yes No    Is hearing impaired

Yes No    Wears contact lenses

Yes No    Has fixed or removable appliances in mouth. List:

Yes No    Has fainted during exercise

Yes No    Has a history of heart disease or diabetes

Yes No    Has asthma or uses an inhalant

Yes No    Is there any reason for the individual to avoid contact

   Please explain any yes responses:

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Note: If there is any concern about your son/daughters medical circumstances and the appropriateness of

participating in lacrosse activities, please get a note of clearance from your doctor.

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Parent signature                                                                      Date