Judo Canada - Membership and event registration

Are you a new or renewing member? *

First Name *

Last Name *

Gender *

Male Female

Date of Birth (YYYY *-MM-DD)

/ /

Club - Is yours missing?

Address *

City *

Province *

Postal Code *

Phone *

Emergency Contact Name *

Emergency Contact Relationship *

# de téléphone du domicile d'urgence *

Emergency Work Phone #

Significant injuries or treatments in the last 6 months

Medicare # *

Medicare Province *

Medicare Expiry date *

Blood Type *

Do you wear glasses/contacts? *

Are you taking any medications? If yes, please provide details *

Do you have any allergies? If yes, please provide details *

Have you had recent weight loss? If yes, provide details including weight loss amount (in kg)

Have you had any recent concussions? If yes, provide details include date(s) *

Head injury *

Seizure/Convulsion *

Heart problems *

High blood pressure *

Blood problems/Bruising *

Asthma *

Diabete *

Menstrual problems *

Abdominal problems *

Heat/Dehydration *

Anaphylaxis *

Skin disorders *

If you answered yes to any of the above, please provide details *

Athlete Digital Signature *

Witness Digital Signature *

Parent Digital Signature (if under 18) *

Judo Canada Medical History Form

Please fix the following errors:

Division

Please fix the following errors:

Division

Which Province/Territory?

Which club do you want to join?

Loading, please wait...

Which club do you want to join?

Loading, please wait...

Contact your club admin to register.

Which club do you want to join?

Loading, please wait...

Which club do you want to join?

Loading, please wait...

Which club do you want to join?

Loading, please wait...

Which club do you want to join?

Loading, please wait...

Which club do you want to join?

Loading, please wait...

Contact your club admin to register.

Which club do you want to join?

Loading, please wait...

Contact your province admin to register.

Which club do you want to join?

Loading, please wait...

Which club do you want to join?

Loading, please wait...