MEDICAL RELEASE AND EMERGENCY INFORMATION FORM by I66t2H

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									Name of Student Athlete: ________________________________________ Grade: ________

E-Mail Address (print clearly): ____________________________________________________

MEDICAL RELEASE AND EMERGENCY INFORMATION FORM

I, ___________________________________, hereby grant permission for my child,
_______________________________, to be examined and treated by a licensed medical physician, team
trainer, or coach for injuries or illness that occur during participation in activities sponsored by Carver
Middle School. I understand that this consent form will only be invoked if school officials are unable to
contact me immediately following the discovery of a need for medical attention. I have listed below any
allergies or pre-existing conditions that may have impact on the treatment of my child.

__________________________            __________________________          ____________
   Parent’s Name (Printed)            Signature of Parent of Guardian         Date

EMERGENCY INFORMATION
Address ________________________________________________________________
Home Phone ___________________
Father’s Name _______________________work # _____________ cell # ____________
Mother’s Name ______________________ work #_____________ cell # ____________
Emergency Contact ___________________ ph # ______________ cell # ____________
Allergies ________________________________________________________________
Current medications _______________________________________________________
Pre-existing medical conditions ______________________________________________
Does the student wear contacts? ____________
Type and name of insurance coverage _________________________________________
Primary care physician and phone # __________________________________________
Hospital preference _______________________________________________________
Any special instructions? ___________________________________________________
________________________________________________________________________
I give Coach Cheatham and Coach Persing permission to take my child off-campus for work-outs. Possible
work-out destinations could include but are not limited to the following: Thomas Dale High School, Henricus
Park, Ironbridge Park, Point of Rocks Park, and Pocahontas State Park. The school activity bus may be used for
travel.
__________________________________                   _____________
          Parent Signature                                 Date

								
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