2019 CC Student Athlete Emergency Form
This form must be filled out before participation in a scrimmage or meet is allowed.
Athlete Name (last, middle, first) *
Your answer
Athlete Grade *
Date of Birth *
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DD
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Emergency Contact #1 - Parent Name *
Your answer
Emergency Contact #1 - Parent Cell Number *
Your answer
Emergency Contact #2 - Name *
Your answer
Emergency Contact #2 - Cell Number *
Your answer
Allergies (if none, put NKA) *
Your answer
Medications (if none, put NA) *
Your answer
Relevant Medical Information (IE - contact lens wearer, family history, asthma, diabetes, etc.) *
Your answer
Today's Date *
MM
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DD
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YYYY
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 existing circumstances. (Typing your name below indicates consent to this statement.) *
Your answer
Insurance Information - Policy Holder Name (optional)
Your answer
Policy Number/Group Number (optional)
Your answer
Insurance Company (optional)
Your answer
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