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. Participant Information - as it appears on your PASSPORT

Question Title

* 2. Date of Birth

Date

Question Title

* 3. Gender:

Question Title

* 4. Function at the Games:
(Select one from the dropdown options)

Question Title

* 5. Sport:
(Select one from the dropdown options.  If you are not affliated with a sport enter NA).

Question Title

* 6. Age Category:
(If this is not applicable select NA)

Question Title

* 7. Dietary Restriction:

Question Title

* 8. Food Allergy:

Question Title

* 9. Medication Allergy:

Question Title

* 10. Other Allergy:

Question Title

* 11. Do you wear a medical ID bracelet:

Question Title

* 12. Are you currently taking any medications prescribed by a physician?

Question Title

* 13. Do you carry and EPI Pen:

Question Title

* 14. Please specify your Blood Type:

Question Title

* 15. Special Medical Condition that requires medication or attention (such as Diabetes, Hypertension, Cardiac conditions, Attention Deficit Disorder, Behavioural, Psychiatric):

Question Title

* 16. 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:

Question Title

* 17. 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 Pan American Maccabi Games in Mexico City, Mexico [and athlete/legal guardian is not able/reasonably available to give consent].

This authorization is effective during the Pan American Maccabi Games from July 5, 2019 – July 15, 2019.

Question Title

* 18. 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 the Pan American Maccabi Games and to the delegation’s support staff including and not limited to: medical team, therapists, communication team, chaperones, coach and manager, if required.

Question Title

* 19. 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.

T