Maccabi International Youth Games Medical Form 2

Medical Form 2 is to be completed by all members of the Canadian delegation and/or the parent/legal guardian of the athlete.

Question Title

* 1. Participant or Athlete Information - as it appears on delegates current PASSPORT

Last Name:

First Name:

Middle Name:
(if not applicable enter NA)

Question Title

* 2. Date of Birth

Date

Question Title

* 3. Gender:

Female

Male

Question Title

* 4. Dietary Restriction:

None

Gluten Free

Sugar Free

Lactose Free

Vegan

Vegetarian

Other (please specify)

Question Title

* 5. Food Allergy:

Yes

If yes, please expand:

Question Title

* 6. Medicine Allergy:

Yes

If yes, please expand:

Question Title

* 7. Special medical attention required:

Yes

If yes, please expand:

Question Title

* 8. I, the above mentioned Maccabi Canada delegation member and/or the parent/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 or the the welfare of my child while said individual is under the care of Maccabi Canada during the Maccabi International Youth Games in Israel [and delegate or parent/legal guardian is not able/reasonably available to give consent].

This authorization is effective during the Maccabi International Youth Games from July 22, 2018 – August 2, 2018.

Participant/Legal Guardian Signature:

Date:

Question Title

* 9. I, the above mentioned Maccabi Canada delegation member and/or the parent/legal guardian, hereby authorize Maccabi Canada to release any information provided to 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

* 10. If an athlete withdraws from participating in the Maccabi International Youth 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 child's non-refundable expenses.

Did you purchase cancellation insurance:

Yes

Question Title

* 11. I am over 19 years-of-age and/or the parent/legal guardian of an athlete, and I have read this form in its entirety and I am familiar with its content.

Participant/Legal Guardian E-Signature(type your name):

Date: