GSW Athletic Medical Information Form
I am the parent(s)/guardian(s) of the student below. I certify that my child/ward is in good physical health and is capable of participation in the sports checked below. No need exists to limit his/her participation. I assume full responsibility for his/her physical condition and participation. I will notify you of any changes in his/her physical condition. If you have any questions you can contact Chris Gibson, Athletic Director.
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Student-Athlete Last Name *
Student-Athlete First Name *
Gender *
Date of Birth *
(MM/DD/YYYY)
Fall Sport
(Choose all that apply)
Winter Sport
(Choose all that apply)
Spring Sport
(Choose all that apply)
Parent / Guardian Name *
Parent / Guardian Phone Number *
Home Street Address *
City *
Parent / Guardian E-Mail Address
(if available)
Emergency Contact #1 *
(First & Last Name)
Emergency Contact #1 Phone Number *
Emergency Contact #2 *
(First & Last Name)
Emergency Contact #2 Phone Number *
Physician Name *
(For student-athlete)
Physician Phone Number
Dentist Name *
(For student-athlete)
Dentist Phone Number
Preferred Hospital or Urgent Care Facility *
Medical History
(Mark all that apply)
Is your student-athlete taking any medication?
(If yes, list below)
Does the student-athlete wear prescription eyewear?
(Example: Glasses or Contacts)
Clear selection
Please provide any other, if any, pertinent medical information related to this student-athlete.
In the event of an injury or illness resulting in the need of emergency medical care and/or transportation to a medical facility, permission is granted to school personnel to proceed with or procure such treatment. *
I understand that, as a condition of my student participating in school-sponsored extracurricular activities, he/she must provide proof of accident and health insurance coverage either by a policy purchased through the District-approved insurance plan or a parent(s)/guardian(s) provided family insurance plan. *
Name of Insurance Company *
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