Field Hockey Pre-Season Player Health Declaration

Player Full Name

Date of Birth

Team

Medical Information

Please list any medical conditions, allergies, or injuries:

Current medications (if any):

Have you had surgery or a major illness in the past 12 months?

Yes No

If yes, provide details:

Has the player tested positive for COVID-19 in the past?

Yes No

If yes, indicate date and any ongoing symptoms:

Is the player currently experiencing any symptoms of illness?

Yes No

If yes, please describe:

Emergency Contact Name

Relationship

Emergency Contact Phone

I declare that the information given is, to my knowledge, complete and correct.

Parent/Guardian Signature

Date