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Methacton School District Emergency Card for Student Athletes-Arcola
Student Athlete Information
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* Indicates required question
Student First Name
*
Your answer
Student Last Name:
*
Your answer
Student Current Grade
*
6
7
8
Date of Birth
*
MM
/
DD
/
YYYY
Sport:
*
Arcola Cheerleading
Arcola Field Hockey
Arcola Football
Arcola Girls Tennis
Arcola Girls Soccer
Arcola Boys Soccer
Arcola Girls XC
Arcola Boys XC
Arcola Girls Volleyball
Arcola Boys Basketball
Arcola Wrestling
Arcola Baseball
Arcola Girls Lacrosse
Arcola Boys Lacrosse
Arcola Softball
Arcola Girls Basketball
Arcola Boys Tennis
Arcola Girls Track & Field
Arcola Boys Track & Field
Arcola Ski/Snowboard Club
Apache Athletic Club
Primary Telephone #:
*
Please use format: 123-456-7890
Your answer
Best email addresses to use for coach/team/club communication:
*
Please include all parent and athlete email addresses separated by a semi-colon.
Your answer
Emergency Contact Person
Emergency Contact Name:
*
Your answer
Relationship to Student Athlete:
*
Your answer
Home Phone:
*
Please use format: 123-456-7890
Your answer
Cell Phone:
*
Please use format: 123-456-7890
Your answer
Email:
Your answer
Student Medical Information
Pre-existing circulatory/pulmonary conditions:
*
If none, please enter "none"
Your answer
Inhalers:
*
If none, please enter "none"
Your answer
Diabetes:
Your answer
Blood Type:
Your answer
Allergies or Allergic Reactions:
*
If none, please enter "none"
Your answer
Medications Being Used:
*
If none, enter "none"
Your answer
Other Patient Health Relation Information:
Your answer
Physician Information
Family Physician Name:
Your answer
Physician Phone:
Please use format: 123-456-7890
Your answer
Name of Insurance:
Your answer
Permission to treat your son/daughter in case of emergency?
*
YES
NO
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