2020 Girl's Student Athlete Emergency Form

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Athlete Name (last, first, middle) *

Athlete Grade *

Date of Birth *

YYYY

Emergency Contact #1 - Parent Name(s) *

Emergency Contact #1 - Parent Cell(s) *

Emergency Contact #2 - Name *

Emergency Contact #2 - Cell *

Allergies (if none, put NKA) *

Medications (if none, put NA) *

Relevant Medical Information (IE - contact lens wearer, family history, asthma, diabetes, etc.) *

Today's Date *

YYYY

I recognize that as a result of athletic participation, medical treatment on an emergency basis may be necessary, and further recognize that school personnel may be unable to contact me for my consent for emergency medical care. I do hereby consent in advance, to such emergency care, including hospital care, as may be deemed necessary under the existing circumstances. (Typing your name below indicates consent to this statement.) *

Insurance Information - Policy Holder Name

Policy Number/Group Number

Insurance Company

My student athlete will be gone over spring break. *

Yes

I don't know.

Other dates I know my student athlete will miss practices or meets: *

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