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St.
Edward Central Catholic High School |
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ATHLETE EMERGENCY INFORMATION
Athlete’s
Name __________________Year in school (circle one) 9 10 11 12 Sport(s)
__________________
Age __________Birthdate
_____________________ Home Phone # ________________________________
Home Address, City & Zip __________________________________________________________________
Father’s Name _________________ Mother’s Name _______________
Guardian’s Name ______________
Father’s Work Phone # ________________________ Alt. # (cell, pager)
____________________________
Mother’s Work Phone # _______________________ Alt. # (cell, pager)
_____________________________
Guardian’s Work Phone #_______________________ Alt. # (cell, pager)
____________________________
Emergency Name & Phone # of 2 people to contact if Parents/Guardian
are not available: ______________
________________________________________________________________________________________
Physician’s Name and Phone # ______________________________________________________________
Physician’s Address _______________________________________________________________________
Dentist’s Name & Phone # __________________________________________________________________
Insurance Carrier/Policy Number _____________________________________________________________
Athlete wears contacts? YES NO Athlete wears glasses?
YES NO
Medication being taken & reason _____________________________________________________________
Allergies (Medication, Insect Bites, etc.) ________________________________________________________
Previous Injuries and Dates of those Injuries (fractures, dislocations,
etc.) _____________________________
Additional information pertinent to athlete’s health (asthma, diabetes,
heart conditions, etc.) ______________
__________________________________________________________________________________________
AUTHORIZATION FOR MEDICAL TREATMENT
I give my consent and permission to any supervising coach of any sport in which my child is or may be participating at St. Edward High School, and the right, on my behalf and in my stand, to arrange for a licensed and certified physician and/or trainers to render and provide immediate treatment to my child as to injuries that may be sustained by my child while participating in such sport, whether directly or indirectly, and whether sustained during practice or in active interscholastic competition, where such injuries consist of, but are not limited to sprains, strains, minor fractures, dislocations, lacerations, contusions, abrasions, and similar injuries, and all without necessity of any further or additional express authorization by me, other than for this authorization. My above permission and consent also extends to the right of any supervising coach or school personnel to arrange for immediate medical treatment by a licensed or certified physician and/or trainer, and for them to apply such emergency techniques as may be necessary to my child where the same, in their judgment, is deemed appropriate by reason of any injury sustained by my child, and where the same, in their judgment, is deemed reasonably necessary to preserve the life or limb of my child.
Name of child to whom the authorization extends _______________________________________________
Signature
of parent/guardian____________________________________ Date ________________________