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Maine Central Institute Athletics Medical Emergency Card
This form must be submitted only once per school year before a student can participate in the athletic program at MCI.
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* Indicates required question
Student Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Parent Name
*
Your answer
Parent Email Address
*
Your answer
Parent Phone Numbers
*
Please provide and specify cell (c), home (h), and work (w) numbers
Your answer
Parent Address
*
Your answer
Other Emergency Contact
*
Please provide relationship to the student as well as name.
Your answer
Other Emergency Contact Phone Number
*
Please specify if number is cell (c), home (h), or work (w)
Your answer
Health Insurance
*
Does your student-athlete have health insurance coverage? If No, please complete this form and contact the Director of Athletics & Activities for more information.
Yes
No
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