2019 CC Student Athlete Emergency Form

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This form must be filled out before participation in a scrimmage or meet is allowed.

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Athlete Name (last, middle, first) *

Athlete Grade *

Date of Birth *

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Emergency Contact #1 - Parent Name *

Emergency Contact #1 - Parent Cell Number *

Emergency Contact #2 - Name *

Emergency Contact #2 - Cell Number *

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 *

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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 (optional)

Policy Number/Group Number (optional)

Insurance Company (optional)

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Formuläret skapades på Pine Island Public Schools ISD 255. Anmäl otillåten användning

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