ACES Athlete Personal Information and Health History Form 2024-2025 Season
PERSONAL INFORMATION
Participant's First and Last Name
Participant's Birthdate
Sex: Male or Female
School Name
Grade:
Parent or Guardian (or Spouse) name:
Parent or Guardian (or Spouse) Occupation:
Cell Phone Number
Home Phone Number
Work Phone Number
Email
Address
If not available in an emergency, notify-NAME AND RELATIONSHIP
EMERGENCY Contact Phone number
Family Health Coverage
We do have family health coverage
We do NOT have family health coverage
Family Dental Coverage
We DO have family dental coverage
We DO NOT have family dental coverage
Health Coverage Info: Insured by: ____________________Policy No. _____________ Subscriber No. ___________________________
Dental Coverage Info: Insured by: ____________________Policy No. _____________ Subscriber No. ___________________________
HEALTH HISTORY
(Check any boxes that apply)
MISCELLANEOUS: Choose any that apply
Ear infections
Rheumatic Fever
Heart Disease
Heart Defects
Convulsions
Hypertension
Diabetes
None apply
IMMUNIZATIONS: Choose any that apply
MMR (Measles, Mumps, Rubella)
DTP Series
Polio OPV (Sabin)
Tetanus
Other
None
DISEASES: Choose any that apply
Mononucleosis
Chicken Pox
Measles
German Measles
Mumps
Asthma
Bleeding Disorder
Clotting Disorder
None apply
ALLERGIES: Choose any that apply
Hay Fever
Poison Ivy
Insect Stings
Penicillin
I carry an Epi pen
I carry an inhaler
Other (fill in below)
None apply
Please Write in any other allergies from question above, write none if applicable
Write in any dietary restrictions, none if applicable
CURRENT MEDICATIONS, write none if applicable
DATES OF OPERATIONS OR SERIOUS INJURIES: Write none if applicable
DISABILITY OR ILLNESS: Write none if applicable
MEDICAL CONTACTS: Name of Family Physician:
Address of Family Physician
Phone Number of Family Physician
MEDICAL CONTACTS: Name of Family Dentist:
Address of Family Dentist
Phone Number of Family Dentist
RECOMMENDATIONS AND RESTRICTIONS WHILE IN THE PROGRAM
Check all that apply below
Choose one
It is OK to give my child Aspirin, Tylenol, Motrin, Benadryl, Neosporin or other over the counter me
It is NOT OK to give my child Aspirin, Tylenol, Motrin, Benadryl, Neosporin or other over t
Special medicines which the participant will need to take during activities, including road trips (list none if applicable)
Limitations (Write none if applicable)
Can this person swim? _________
Yes
No
Other comments:
CONSENT TO MEDICAL CARE
This health advisory is correct so far as I know, and the person herein described has permission to engage in all prescribed activities, except as noted by me on this health form. The undersigned, as parent or legal guardian of the child registered on this form, hereby authorizes ACES and its delegated leaders and directors to consent to any medical and hospital care to be rendered to said minor upon the advice of a licensed physician. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. It is understood that if time and circumstances reasonably permit, ACES will endeavor, but it is not required, to communicate with me prior to such treatment. The undersigned further agrees that the ACES and its designated leaders and directors are not legally or financially liable for any claim rising from any consent given in good faith in connection with such diagnosis or advised treatment. This authorization and consent to treatment of minor is given to the ACES in conjunction with any authorized event.
Name of Parent of Legal Guardian:
Parent or Legal Guardian’s Signature:
*
Clear
Date
Submit