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Emergency Medical Form for Coaches
Emergency medical forms should be completed for student athletes by their parents. They should be available for coaches and trainers during practices and athletic competition.
Athlete's Name: *
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Athlete's Birthdate: *
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Athlete's Grade *
Athlete's Address: *
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Athlete's Home Phone: *
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Father's Name: *
Your answer
Father's Cell Phone Number: *
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Mother's Name: *
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Mother's Cell Phone Number: *
Your answer
Emergency contact if parents are not available: *
In the event of an injury, all effort will be made to contact the student's parent first. Please provide the names of an emergency contact should the coach/ trainer be unable to reach the parent.
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Emergency contact's relationship to student athlete: *
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Emergency contact's phone number: *
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Family Physician: *
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Family Physician Phone Number: *
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Hospital Preference: *
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Family Health Insurance Provider: *
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Date of last tetanus/booster shot: *
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Please list health problems coach should be aware of (include allergies, i.e. food, medications) *
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Please list any medications student athlete is currently taking: *
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Emergency Treatment Consent Release: *
I recognize that as a result of athletic participation, medical treatment on an emergency basis may be necessary and further recognize that school personnel may be unable to contact me for my consent for emergency medical care. I do hereby consent, in advance, to such emergency care as may be deemed necessary under the then existing circumstances. I also give my consent for my son/daughter to accompany the team on trips and will not hold the school responsible in case of accident or injury, whether it is en route to or from another school or during practice of an interscholastic event.
Name of Parent Completing Form *
Your answer
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