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Hartland Consolidated Schools Athletics Emergency and Emergency Contact Form
2017-2018
Student Athlete's Gender *
Student Athlete's Last Name *
Your answer
Student Athlete's First Name *
Your answer
I, ______________________________ (parent/guardian’s name), acknowledge that my child,_________________________________ (athlete's name) may be injured as a result of participation in athletics for Hartland Consolidated Schools. I give the athletic trainer, coaches, administrators, and staff permission to provide appropriate emergency care to my child. *
Type parent/guardian's name then enter the athlete's name.
Your answer
Signature *
I understand this is a legal representation of my signature.
Your answer
Please include ALL the information requested below. In the instance that an emergency situation should develop with your child and medical attention is needed this information will be of assistance to the appropriate medical personnel.
Student Athlete's Age *
Student Athlete's Date of Birth *
MM
/
DD
/
YYYY
Student Athlete's Grade Level *
KNOWN ALLERGIES *
If none, type "None" in the space below.
Your answer
CURRENT MEDICATIONS *
If none, type "None" in the space below.
Your answer
CURRENT MEDICAL CONDITIONS *
If none, type "None" in the space below.
Your answer
Are there any medications your student athlete should self-carry while running? *
Examples are: Inhalers for asthma or Epipens for bee/other allergies.
If you answered "yes" to the question above, please list them below and follow the link to complete the required self-carry medical form. THE FORM MUST HAVE A DOCTOR'S SIGNATURE.
Your answer
EMERGENCY CONTACT #1
Name *
Your answer
Relation to Athlete *
Your answer
Phone Number *
Your answer
EMERGENCY CONTACT #2
Name *
Your answer
Relation to Athlete *
Your answer
Phone Number *
Your answer
EMERGENCY CONTACT #3
Name
Your answer
Relation to Athlete
Your answer
Phone Number
Your answer
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