Health and Accident Form

Please fill out the health and accident form below and submit.

Health and Accident Form

This form is confidential and shall remain in effect until such a time as the person who signs this form indicates in writing any change of information. In case of any changes, please notify a member of the BSC Board immediately.

The applicant agrees that the Blenheim Skating Club and/or its proprietors and coaches will not be held responsible for any loss, however caused, and agrees to the release of the proprietors and/or coaches from all claims or damages which may arise as a result of or by reason of such injuries or loss of any nature whatsoever. If any injury takes place while on the ice, please notify someone in charge at the time, so if the injury is severe in nature an ambulance can be called and an accident report can be filed, and if necessary, a claim can be sent to our insurance company.

Skaters First Name

Skaters Last Name

Parent(s) Full Name

Serious injury is defined as: Broken or dislocated limbs, concussions, serious bleeding etc. I trust the Coaches/B.S.C executive’s opinion first and request that I be contacted immediately. I give permission for my child to be transported by ambulance if the need arises.

Medical issues to be aware of:

Yes

Date

Initials

I confirm that the information given in this form is true. I understand that Skate Canada has implemented a mandatory helmet policy for all skate levels up to and including CanSkate 5 and further understand that all helmets must be CSA approved and within date code. I understand that bike, ski and snow sport helmets are not permitted. I agree to ensure this skater complies with this policy at all times as required.

Thanks for submitting!