Canyon Creek Athlete Emergency Information 2022-23
This form is required for all student-athletes participating in Canyon Creek athletic after school programs.  Paper versions of this form are available if you are not comfortable putting any of the information requested into an electronic form.  The information requested is for coach and office use only and will not be used to contact you or anyone else for any reason other than track or an emergency. Please email ddentremont@nsd.org and provide your student's name, grade, and classroom teacher to receive a paper form, or come to the Canyon Creek main office for a copy.
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Student Name *
Student Number (7 digits) *
Grade *
Does your child have special medical needs or a life- threatening condition such as severe allergies, asthma, seizures, diabetes, etc.? *
Please provide the details of your student's medical needs or life-threatening condition(s) or write "via email" and email ddentremont@nsd.org with the details. If no condition, write "none" or n/a. *
Name of Parent/Guardian *
Address (include city/zip) *
Parent/Guardian Phone *
(Optional) Additional phone number
Name of Physician *
Phone number of Physician. *
Hospital or Clinic Organization *
Name of Insurance Company *
Parent/guardian email *
First and last name of Emergency Contact if Parent/Guardian is not available: *
Phone number of Emergency Contact: *
(Optional) First and last name of additional emergency contact.
(Optional) Phone number of additional emergency contact.
Has your student had a head or neck injury in the last 90 days? *
If your student has had a head or neck injury in the last 90 days, please enter the date of the injury below.  If no injury, you may skip this question.
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Please sign this form by entering your name below. *
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