Games Medical Form 2 Medical Form 2 is to be completed by all members of the Canadian delegation or the legal guardian for athletes under 19 years of age. Question Title * 1. Did you participate in the 19th Maccabiah (2013): Yes No Question Title * 2. Participant Information - as it appears on your PASSPORT Last Name: First Name: Middle Name:(if not applicable enter NA) Question Title * 3. Date of Birth Date Date Question Title * 4. Gender: Female Male Question Title * 5. Function at the Games:(Select one from the dropdown options) Athlete Chaperone Coach Communications Doctor Executive Family Member Logistics Manager Therapists Question Title * 6. Sport:(Select one from the dropdown options. If you are not affliated with a sport enter NA). N/A Artistic Gymnastics Baseball Basketball Beach Volleyball Cycling Golf Half Marathon Hockey Rhythmic Gymnastics Soccer Softball Squash Swimming Tennis Track & Field Triathlon Volleyball Waterpolo Wrestling Question Title * 7. Age Category:(If this is not applicable select NA) NA Masters Open Juniors Question Title * 8. Dietary Restriction: None Gluten Free Sugar Free Lactose Free Vegan Vegetarian Other (please specify) Question Title * 9. Food Allergy: Yes No If yes, please expand: Question Title * 10. Medicine Allergy: Yes No If yes, please expand: Question Title * 11. Special medical attention required: Yes No If yes, please expand: Question Title * 12. I, the above mentioned Maccabi Canada delegation member and/or their legal guardian hereby authorize Maccabi Canada, its physicians and other medical staff, including physiotherapists to provide any medical care determined by a Maccabi Canada medical professional to be necessary for my welfare (the welfare of my child) while said individual is under the care of Maccabi Canada during the Maccabiah Games in Israel [and athlete/legal guardian is not able/reasonably available to give consent].This authorization is effective during the Maccabiah Games from June 29, 2017 – July 19, 2017. Participant/Legal Guardian Signature: Date: Question Title * 13. I, the above mentioned Maccabi Canada delegation member and/or their legal guardian, hereby authorize Maccabi Canada to release any information I provided Maccabi Canada throughout the registration process to the organizing committee of Maccabi World Union and to the delegation’s support staff including and not limited to: medical team, therapists, communication team, chaperones, coach and manager, if required. Participant/Legal Guardian Signature: Date: Question Title * 14. If an athlete withdraws from participating in the Games for ANY reason, Maccabi Canada will strictly adhere to its refund policy. We strongly encourage you to purchase travel and cancellation insurance to cover your non-refundable expenses.Did you purchase cancellation insurance: Yes No Question Title * 15. I am over 19 years-of-age and/or the parent or legal guardian of a junior athlete, and I have read this form in its entirety and am familiar with its content. Participant/Legal Guardian E-Signature(type your name): Date: Done
