BPHS Athletic Emergency Information Form

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Please complete this form so we have the necessary information to contact you if there is an emergency.

Student Last Name *

Student First Name *

Student Address *

Home Phone Number *

Student Date of Birth *

年

月

日

Parent/Guardian Name *

Emergency Contact Phone Number *

Family MD *

Family MD Phone Number *

Allergies/Medical Conditions

Medications

Parent/Guardian Authorization

If I cannot be reached in an emergency, I hereby consent for a qualified physician or surgeon to examine, diagnose, and to prescribe or perform treatment, including surgery, that is deemed advisable for the welfare of the above-named participant.

Please enter your name below to give authorization and consent: *

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