Athlete:  ________________  Sport:  ________________

 

In case of Emergency, I __________________________ give permission for my son/daughter to be treated by medical personnel on site at a school sporting event.

Day time phone number  _______________________

Home phone number  _____________________

Person to contact if unavailable:  _________________  

Contact’s phone number:  __________________

My son/daughter suffers from (please circle any):

Allergies:  _______________________________________

Asthma?  Yes   No  

Inhaler?  Yes   No   

Daily meds? Yes    No

Diabetes?  Yes    No    

Insulin   Yes    No

Seizures?   Yes    No    

Medication?  _____________________

Other medical conditions:  _______________________________________

Any daily medications:  _________________________________________

_____________________________________________________________

Preferred Hospital:  _____________ 

Insurance Company:  _____________

Card holder:  __________________ 

ID#:  _________________________

Parent Signature:  ________________________

Date:  ______________