(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)