"SAINT FRANCIS HIGH SCHOOL"
SAINT FRANCIS HIGH SCHOOL ATHLETIC DEPARTMENT EMERGENCY FORM INFORMATION Legal Name of Student Year of Graduation Last First Middle Date of Birth Home Address City State/Zip Home Phone Father’s/Mother’s Names Father’s Work Phone Mother’s Work Phone Cell /Pager Cell/Pager e.mail e.mail In the event of illness or accident, when we cannot be reached, we wish one of the following to be notified by telephone. They have been authorized to act in or absence and will be informed that their names have been given to the school for this purpose. (Please list people who would be able to come pick up your child in case of illness or emergency.) Name Phone Name Phone Doctor Phone Dentist Phone Student resides with: Parents _______ Mother _______ Father _______ Other Please answer the following questions: 1. Does your child have any allergies? YES NO _______ If yes: WHAT 2. Is your child on a continuing medication program, i.e., Insulin, Dilantin, Paxil, Ritalin? YES _______ NO _______ If yes: WHAT 3. Medical Insurance Policy # 4. Dental Insurance Policy # In case of an emergency, Saint Francis High School is authorized to take any necessary measures to care for my child and will not be held liable for such acts. Father’s Name Father’s Signature Date (print) Mother’s Name Mother’s Signature Date (Both signatures are required when parents are living together) Revised 8/2004