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 ___________________________