Please enable JavaScript in your browser to complete this form.To ensure that players are provided with the safest environment possible, this Player Support Plan is aimed at assisting coaches and volunteers in better understanding the individual needs of each player. It is understood that coaches will do their best to implement necessary support strategies whenever possible. PLAYER INFORMATION Name *FirstLastJersey NumberDate Of Birth *Age *Diagnosis *SAFETY/MEDICAL ALERT Note any vital safety or medical information here. Include previous injuries and/or concussion history. *STRENGTHS List players strengths here *COGNITIVE ABILITY – How well is the player able to understand events and conversations? (check one) *Very WellWellSomewhatNot at allVaries significantly depending on stress/anxietyHow well is the paly able to read/understand written material? (check one) *Very WellWellSomewhatNot at allVaries significantly depending on stress/anxietyASSISTIVE DEVICES/INDIVIDUALIZED EQUIPMENT List any specialize assistive devices or individualized equipment (i.e., hearing aids, glasses, brace, etc.) that will be used by the player while participating on the ice during practices and games.PLAYER CONSIDERATIONS (check all that apply)Does not like loud noisesDoes not respond well to yellingHas visual impairmentIs obsessive-compulsiveBecomes confused easilyNeeds reminders to hydrateIs easily distractedHas difficulty with changeExhibits self-stimulating behavioursIs prone to anxietyHas difficulty understanding non-verbal communicationDoes not like whistlesHas limited verbal skillsHas a hearing impairmentMay run away/leaveIs easily upset (sad, crying)Is prone to seizuresHas a short attention spanIs hyperactiveMay become aggressive if upsetIs easily angeredOtherWith respect to the player considerations checked above, please note any strategies that may be useful to help the player manage:I give my consent to have the above-mentioned information shared with the ELECTRIC CITY coaches, volunteers, Player Support team & Board of Directors (as necessary) Signature Required – Player signature(if over 18 years old or able) OR Parent/GuardianClear SignatureDate Person Accepting Clear SignatureAcceptance Date Submit
