Athletic Emergency Information

							                      Athletic Emergency Information
                                         (please print)

Students Name _____________________________ Date of Birth ___________ Age ________
Students Address ________________________________________________ Grade _________
Students SS Number ____________________________________________________________

Father’s Name _________________________ Mother’s Name __________________________
Father’s Address _______________________ Mother’s Address _________________________
Father’s home number __________________ Mother’s home number ____________________
Father’s Employer ______________________ Mother’s employer _______________________
Father’s Work number ___________________ Mother’s Work Number __________________
Father’s Cell __________________________ Mother’s Cell ____________________________

Student’s Physician name and phone ________________________________________________

Another person to call in an emergency & phone ______________________________________

Special conditions that should be known by coaches: __________________________________
_____________________________________________________________________________

Medications taken regularly _________________________ Allergies _____________________


If you have group coverage for your child, then your insurance is the primary coverage and the
student insurance is secondary.

Name of Fathers Employee Group Health Insurance & phone ____________________________

Deductible ______________________ Policy and/or group number ______________________

Name of mother’s employee Group Health Insurance & phone ___________________________

Deductible _____________________ Policy and/or group number ______________________

If, in the judgment of any representative of the school, the student named above, should need
immediate care and/or treatments as a result of any injury or sickness, I do hereby request,
authorize and consent to such care and treatment as may be given said student by any physician,
coach, teacher, nurse or school representative and release from any claim by any person
whosoever on account of such care and treatment of said student. A photocopy of this
authorization is to be considered as effective and valid as the original.

Signature of Parent/Guardian _____________________________________________________

Date _________________________________________________________________________