Registration Form | Calgary Rage

First name

Last name

Email

Phone Number

Address

Birthdate

Name of Parent/Guardian (if under 18)

Alberta Health Care Number

Medical Questionnaire - Select all That Apply

I have allergies

I have a family history of high blood preasure

I have been diagnosed with a heart murmur

I have passed out or become dizzy from excercise

I have had a stinger; burner or a pinched nerve

I have had heat cramps or muscle cramps requiring medication

I have been treated for a medical condition in the last 3 months

I have a blood born illness

I wear glasses or contacts

I wear a dental appliance

I wear special equipment; Braces; Splints; Eye Guards etc

I wear a medic alert bracelet

None

If you have selected any options above please explain.

Have you had a concussion or a head injury? If yes, please provide as many details as possible. Month/ Year

If you have selected any of the above list please specify injuries including side of body

I have completed the medical conditions questionnaire to the best of my knowledge and have not willingly withheld information on any prior condition or injury for which I am currently being treated.

Yes

No

I recognize the importance of the medical conditions questionnaire in assisting the coaches and trainers in providing prompt and accurate medical attention.

Yes

No

I am aware that the team staff member(s) attending to my injury may need to clarify any previous condition or injury that I may have sustained.

Yes

No

I understand that any medical information I disclose will be kept confidential unless it is necessary to divulge it to another medical practitioner/facility.

Yes

No

Please type your name to indicate your understanding and acceptance of the above consent statements. If the participant is under the age of 18, please have the parent/guardian enter their name below.

I give my consent for any pertinent medical information regarding any injuries or medical conditions that may affect my ability to participate to be disclosed to the designated athletic therapist(s).

Yes

No

All Rage activities may be filmed or photographed for training and/or PR/marketing purposes. I consent to my photo/image or video footage to be used for these purposes.

Yes

No

I agree to WAIVE ANY AND ALL CLAIMS that I have or may in the future have against The Rage, and its directors, officers, employees, agents, representatives, assigns, and successors.

I Agree

Release

I agree to RELEASE THE RAGE and its directors officers employees agents representatives assigns and successors from any and all liability for any loss; damage; injury; or expense that I may suffer as

INCLUDING NEGLIGENCE; BREACH OF CONTRACT; BREACH OF STATUTORY DUTY OF CARE; AND/OR BREAK OF THE OCCUPIER'S LIABILITY ACT R.S.A. 2000 C.0-4 ON THE PART OF THE RAGE and its directors officers employees

Please type your name below to provide your electronic signature with intent, indicating your agreement with the waiver statements above. Parent or Guardian if the participant is under 18 years of Age

Camp Registration

November Camp