Health Questionnaire & Authorization
In case of an emergency, parent/guardian authorizes their child’s coach to obtain medical treatment for their child in accordance with school policies and procedures. Health information and emergency contacts should be identified on the health questionnaire card below and returned with other required forms.
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Email *
Student/Athlete Name *
Student/Athlete Grade Level *
Parent Name(s) *
Home Phone *
Mobile Phone *
Other Phone
Physician's Name & Number *
Emergency Contact (include name, relationship and phone #). *
Health Concerns (please check either Yes OR No for all conditions). *
Yes
No
Concussion History
Head/Neck/Cervical Spine Injuries
Heart Condition/Disease
Exertional Heat Stroke in the past?
Asthma
Diabetes
Epileptic
Kidney injuries/condition
Do you wear contact lenses?
Use an inhaler?
Use an Epipen?
Allergic to medications?
Environmental/Seasonal Allergies?
Concussion History (Please Explain frequency). *
Heart Disease/Condition (Please Explain) *
Asthma (is inhaler necessary and carried student?) *
Required
Allergies to Food (please explain: List food type - reaction -  and response protocol or if Epipen is required) *
Allergies to Medication  (please explain and note if Epipen is needed) *
Allergies to Environmental/Seasonal aspects (bees, pollen, ragweed, etc...)  -  please explain and note if Epipen is needed. *
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