South County Street Hockey League
Medical Information Form
For players under age 18
Use this form while registering with USA Hockey to notify the SCSHL coaches of any medical conditions and to authorize emergency treatment. Print this form, fill it out and bring it to one of our registration sessions or to your first scheduled session.  If there are any questions concerning registering for this division, please call 789-3896 and press 6 to leave a message for a league official or use the email link on our web site: www.streethocky.org
Please Circle Your Division:
Instructional(ages 6-8)               Junior (ages 9-12)                    Senior(ages 13-17)
Participant's Name:
Medical conditions that coaches need to be aware of (allergies, etc). If none, please write "none":
Name of participant's physician or medical group:
I/we know that participation in hockey may result in serious injuries to my/our child. Protective equipment does not prevent all injuries to players. In case of an emergency, if a family physician cannot be reached I hereby authorize the above named participant/individual to be treated by another physician who is available.
Parent or Guardian's Signature: Date: