Methacton School District Emergency Card for Student Athletes-Arcola
Student Athlete Information
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Student First Name *
Student Last Name: *
Student Current Grade *
Date of Birth *
MM
/
DD
/
YYYY
Sport: (a new form must be completed for each season/sport) *
Primary Telephone #: *
Please use format: 123-456-7890
Best email addresses to use for coach/team/club communication: *
Please include all parent and athlete email addresses separated by a semi-colon.
Emergency Contact Person
Emergency Contact Name: *
Relationship to Student Athlete: *
Cell Phone: *
Please use format: 123-456-7890
Email:
Student Medical Information
Pre-existing circulatory/pulmonary conditions: *
If none, please enter "none"
Inhalers: *
If none, please enter "none"
Diabetes:
Blood Type:
Allergies or Allergic Reactions: *
If none, please enter "none"
Medications Being Used: *
If none, enter "none"
Other Patient Health Relation Information:
Physician Information
Family Physician Name:
Physician Phone:
Please use format: 123-456-7890
Name of Insurance:
Permission to treat your son/daughter in case of emergency? *
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