Student Emergency/Medical Information Card
Name
*
Last Name
First Name
Middle Initial
School
*
Grade
*
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Gender
*
Please Select
Male
Female
Birthdate
*
-
Month
-
Day
Year
Date
Language Spoken at Home
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different from home address above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Select number of Parent/Guardian
*
Please Select
1
2
Parent/Guardian 1 Name
*
First Name
Last Name
Employer
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Parent/Guardian 2 Name
*
First Name
Last Name
Employer
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Child Lives With
*
Mother & Father
Mother
Father
Caregiver/Guardian
Other
Emergency Contacts
In case child listed above becomes ill or is injured during sports activity and I cannot becontacted, the athletic department has my permission to contact and release my child to the custody of one of the following:
Emergency Contact 1 Name
*
First Name
Last Name
Emergency Contact 1 Relationship With Child
*
Emergency Contact 1 Phone Number
*
Please enter a valid phone number.
Emergency Contact 2 Name
*
First Name
Last Name
Emergency Contact 2 Relationship With Child
*
Emergency Contact 2 Phone Number
*
Please enter a valid phone number.
Emergency Contact 3 Name
First Name
Last Name
Emergency Contact 3 Relationship With Child
Emergency Contact 3 Phone Number
Please enter a valid phone number.
Child’s Pediatrician Name
*
Pediatrician Phone Number
*
Please enter a valid phone number.
My Child Has Health Insurance
Yes
No
List Member #
My child receives regular care for the following medical condition(s)
Allergies
Yes
No
Allergies requiring Epinephrine
Yes
No
List of Allergies
Date of Last Reaction
-
Month
-
Day
Year
Asthma
Yes
No
Diabetes
Yes
No
Insulin Required
Yes
No
Does your child have any other major health issues or special needs? Please list
Is your child taking medication(s)? Please list medication(s) and times taken
If my child needs to taken to an emergency facility, he/she will be taken to the nearest one. I give my consent for the Athletic Department to take appropriate action for the safety and welfare of my child.
Parent/Guardian Signature
Submission Email
*
example@example.com
Submit
Should be Empty: