Port Angeles High School
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MEDICAL EMERGENCY AUTHORIZATION FORM

(TO BE COMPLETED BY PARENT AND RETURNED TO
HEAD COACH)

(Student
Name):__________________________________ Date:______________________

(Student School ID#):__________________________ Grade in
School________________

Have you graduated from high school?
No: ____________Yes:_________

Date of
Birth:________________Height:______________________Weight:___________

List of Any Allergies:__________________________

List of Required Medication:___________________________

Other Medical History

Family Physician’s
Name:___________________________ Phone:__________________

CONTACT INFORMATION

Parent’s
Name:___________________________ Home Phone:__________________

Work Phone:___________________________ Cell
Phone:__________________

Address:___________________________

Emergency Contact Person:___________________________
Phone:__________________

Relationship of Contact
Person:___________________________

Name of Family Insurance
Company:_______________________ Policy #______________

MEDICAL EMERGENCY AUTHORIZATION

Name of Student
Athlete:___________________________

As Parent or Legal
Guardian, I authorize the team physician or, in his absence, a
qualified physician to examine the above-named student and in the
event of injury to administer emergency care and to arrange for any
consultation by a specialist, including a surgeon, he deems
necessary to insure proper care of any injury. Every effort will be
made to contact parent or guardian to explain the nature of the
problem prior to any involved treatment.

Name
________________________________:::Date: _________________

(Signature of Parent or Guardian)

Information