| NAME | ___________________________________________________________ |
| OHIP/HEALTH CARD NO. | ___________________________________________________________ |
| ALLERGIES | ___________________________________________________________ |
| | ___________________________________________________________ |
| | ___________________________________________________________ |
| | ___________________________________________________________ |
| DOCTOR'S NAME | ___________________________________________________________ |
| DOCTOR'S PHONE | ___________________________________________________________ |
| DENTIST'S NAME | ___________________________________________________________ |
| DENTIST'S PHONE | ___________________________________________________________ |
| |
| PERSON TO CONTACT IN CASE OF EMERGENCY: |
| NAME | ___________________________________________________________ |
| RELATIONSHIP | ___________________________________________________________ |
| PHONE HOME | _________________________WORK____________________________ |
| |
| I understand that no member of the Waterloo Women's Field Hockey Club or the Club itself may be held
responsible for any injury which might occur that is related in any way to participation in the
activities of the Waterloo Women's Field Hockey Club. |
| |
SIGNED
| __________________________________________________
(signed by parent or guardian if under 18 years old) |
| |
| DATED | __________________________________________________ |
PLEASE RETURN THE PERSONAL INFORMATION SHEET, THE REGISTRATION FORM AND THE CHEQUE TO:
Waterloo Women's Field Hockey Club
c/o 141 Wake Robin Drive
Kitchener, ON, N2E 3L6 |
