2018 PIVB Emergency Contact Form

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Athlete Last Name: *

Athlete First Name: *

Team (Select all that apply): *

C-Squad

Varsity

Required

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 (optional)

Policy Number/Group Number (optional)

Insurance Company (optional)

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