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(TO BE COMPLETED BY PARENT AND =
RETURNED TO=20
HEAD COACH)
(Student=20
Name):__________________________________ =
Date:______________________=20
(Student School ID#):__________________________ =
Grade in=20
School________________
Have you graduated from high =
school?=20
No: ____________Yes:_________
Date of=20
=
Birth:________________Height:______________________Weight:___________=20
List of Any Allergies:__________________________=20
List of Required =
Medication:___________________________=20
Other Medical History
Family Physician=92s=20
Name:___________________________ Phone:__________________=20
CONTACT INFORMATION
Parent=92s=20
Name:___________________________ Home =
Phone:__________________=20
Work Phone:___________________________ Cell=20
Phone:__________________ =
Address:___________________________=20
Emergency Contact Person:___________________________ =
Phone:__________________
Relationship of Contact=20
Person:___________________________
Name of Family =
Insurance=20
Company:_______________________ Policy #______________=20
MEDICAL EMERGENCY AUTHORIZATION
Name of =
Student=20
Athlete:___________________________
As Parent or =
Legal=20
Guardian, I authorize the team physician or, in his absence, =
a=20
qualified physician to examine the above-named student and =
in the=20
event of injury to administer emergency care and to arrange =
for any=20
consultation by a specialist, including a surgeon, he deems=20
necessary to insure proper care of any injury. Every effort =
will be=20
made to contact parent or guardian to explain the nature of =
the=20
problem prior to any involved treatment.
Name=20
________________________________:::Date: _________________=20
(Signature of Parent or Guardian)=20
=
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