Please Fill out Top and Bottom for One Sport Only
Total Page：16
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PLEASE FILL OUT TOP AND BOTTOM FOR ONE SPORT ONLY
EMERGENCY DATA
COACHES’ COPY
SPORT ______STUDENT’S NAME ______DOB______GRADE_____ PARENTS’S NAME ______ADDRESS______TELEPHONE: HOME ______WORK ______CELL______PERSON TO NOTIFY IF PARENT/GUARDIAN NOT AVAILABLE: ______ADDRESS: ______TELEPHONE: HOME ______WORK______CELL______PHYSICIAN ______PHONE ______DENTIST______PHONE ______HOSPITAL PREFERENCE______IN CASE OF EMERGENCY AND YOU ARE NOT AVAILABLE, DO WE HAVE PERMISSION TO TAKE YOUR CHILD TO A HOSPITAL? ______YES ______NO PRE-EXISTING MEDICAL CONDITION (i.e. Asthma) ______LIST MEDICATION STUDENT IS CURRENTLY TAKING______
______PARENT/GUARDIAN SIGNATURE DATE
A copy will be given to your son’s/daughter’s coach and the athletic trainer so that information will be available if they are not on school premises.
EMERGENCY DATA
TRAINERS’ COPY
SPORT ______STUDENT’S NAME ______DOB______GRADE_____ PARENTS’S NAME ______ADDRESS______TELEPHONE: HOME ______WORK ______CELL______PERSON TO NOTIFY IF PARENT/GUARDIAN NOT AVAILABLE: ______ADDRESS: ______TELEPHONE: HOME ______WORK______CELL______PHYSICIAN ______PHONE ______DENTIST______PHONE ______HOSPITAL PREFERENCE______IN CASE OF EMERGENCY AND YOU ARE NOT AVAILABLE, DO WE HAVE PERMISSION TO TAKE YOUR CHILD TO A HOSPITAL? ______YES ______NO PRE-EXISTING MEDICAL CONDITION (i.e. Asthma) ______LIST MEDICATION STUDENT IS CURRENTLY TAKING______
______PARENT/GUARDIAN SIGNATURE DATE