Skip to main content
Athletics Handbook » Emergency Information/Health Form

Emergency Information/Health Form

 
 
To be completed by Parent/Guardian     
                                                                                                                       SPORT________________________
 
Name  __________________________________Date of Birth ________________ Grade:__________
 
Address  ________________________________________________________________________________
 
Town/State  __________________________ Zip _____________  Phone ________________________ 
 
Parent/Guardian
Father   Mother   
Address Address
Place of Employment    Place of Employment   
Home#                            Wk#            Home#                            Wk#               
Cell#    Cell#   
E-mail address:   E-mail address:  
 
                                                                                                                                              
IN CASE OF EMERGENCY WHEN PARENT/GUARDIAN CANNOT BE REACHED,
PLEASE NOTIFY:
 
Name of Responsible Person ________________________________ Relationship _________________   
 
Address ___________________________________________________                                                               
 
Phone   _______________________________________                                                         
 
 
MEDICAL/HEALTH INFORMATION
 
Name of Insurance Company _________________________________________________________                 
 
Policy#  ___________________________________   Type of Coverage  _______________________
 
Physician’s Name:____________________________ Phone Number:_________________________
 
 
 
CONSENT TO PARTICIPATION AND ACKNOWLEDGEMENT OF RISKS
 
I hereby acknowledge an awareness that participation in the sport of. _____________ involves a risk of injury, which may include severe injuries possibly involving paralysis, permanent mental disability, or death, and that these injuries may occur in some instances as a result of unavoidable accidents. I accept these risks in giving consent to participation in (sport)   ___________________ during the (school vear)_____________ season by the undersigned athlete.
 
 
 
PERMISSION TO PROVIDE EMERGENCY TREATMENT
 
On rare occasions an emergency arises and we are unable to contact the parent/guardian. In order that no delay occur that may jeopardize the life of the student, the school requests permission from the parent/ guardian to seek emergency treatment.

I hereby grant permission to the Milford School District to administer First Aid, administer epinephrine if necessary, secure proper medical treatment and/or hospitalize my son/daughter in case of emergency, provided they are unable to communicate with me, and according to their best judgment, further delay might jeopardize the life of my
son/daughter.

Parent/Guardian's Signature ____________________________________ Date ___________________________