MEDICAL EMERGENCY AUTHORIZATION FORM
(TO
BE COMPLETED BY PARENT AND RETURNED TO HEAD COACH)
Name
Date
(Student)
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)