St. Edward Central Catholic High School

335 Locust Street, Elgin, IL 60123

847-741-7535 School Office

847-741-7536 Athletic Office

847-488-9930 Athletic Office Fax

 

Athletic Home Page

 

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 ________________________