2022-2023 Emergency/Consent Form
This information will be given to coaches and the athletic trainer to have accessible at all practices & games. It will also be kept on file to insure consent has been given for the student-athletes to receive medical treatment. Please take the time to fill out the form. Must be completed by a parent or a guardian.
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Last Name *
First Name *
Date of Birth *
Grade Level *
Sport *
Parent's (or guardian's) Name *
Parent/Guardian Cell # *
Parent/Guardian Work #
Parent #2 (or guardian's) Name *
Parent/Guardian #2 Cell # *
Student's Cell Phone # (Optional but helpful for AT & Coaches)
Address (street, city, zip) *
Another Emergency Contact's Name (should not be parent/guardian-you will be called first. This is in case you cannot be reached). *
Another Emergency Contact Cell # *
Allergies? (if none, type n/a) *
Current prescribed medications? (if none, type n/a) *
Diabetes? Asthma? Sickle Cell?  (if none, type n/a) *
Has your child been diagnosed with a previous concussion? *
If you answered yes to the question above, please state how many & when the concussion/s occurred.
Has your child tested positive for COVID? *
If you answered yes; what date did your child test positive?
If your child had COVID was it a mild, moderate or severe case? Mild= fever, cough, sore throat, malaise, headache, muscle pain, nausea, vomiting, diarrhea, loss of taste and smell but who do not have shortness of breath, dyspnea, or abnormal chest imaging. Moderate=evidence of lower respiratory disease during clinical assessment and who have an oxygen saturation (SpO2) ≥94% on room air at sea level. Severe=Individuals who have SpO2 <94% and hospitalized.
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Known drug reactions? (if none, type n/a) *
Any other information you feel is important to have on file?
Important reminder: If a student athlete is taken to the doctors, FOR ANYTHING, there must be a doctors note given to the athletic trainer and/or coach describing why the student was seen and if there are any restrictions or full clearance for activity. This is for liability and safety reasons. Please type your initials here acknowledging you understand and will adhere to this rule so that your athlete does not have to sit out. *
MEDICATION PERMISSION: The following medications can be made available for all athletes deemed necessary by the athletic trainer following guidelines and directions of a team physician: Cough drops, antihistamine tablets, non-aspirin pain relief, antacid tablets, anti-diarrhea tablets, electrolyte replacement tablets, antibiotic ointment, and hydrocortisone cream.  ***** I give my son/daughter permission to receive these medications. *
I, the parent or guardian, give permission for this student to participate in sport activities and receive care/treatment from the coaches and the certified athletic trainer. 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, including hospital care, as may be deemed necessary under the circumstances and to assume the expenses of such care. BY TYPING MY FULL NAME IN THE BELOW SPACE I AGREE TO ALL OF THE ABOVE. *
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