Emergency Permission Form - Spring 2017
What is your athlete's first name?
Your answer
What is your athlete's last name?
Your answer
What is your athlete's age?
Your answer
What grade is your athlete in?
Your answer
What is today's date?
Your answer
What sport is your student planning to participate in this season?
Please list any medications the athlete is currently taking?
Your answer
Please list any medications your athlete may be allergic to?
Your answer
What is the name of the parent/guardian?
Your answer
What is the parent/guardian's home phone number?
Your answer
What is the parent/guardian's cell phone number?
Your answer
What is the parent/guardian's e-mail address?
Your answer
In the event I cannot be reached in an emergency, I hereby give permission to physicians selected by the athletic training and/or coaching staff of CHS to hospitalize, secure proper treatment for and to order injection and/or anesthesia and/or surgery for the person named above?
In the event I cannot be reached in an emergency, I DO NOT give permission to physicians selected by the athletic training and/or coaching staff of CHS to hospitalize, secure proper treatment for and to order injection and/or anesthesia and/or surgery for the person named above?
What is the name of the athlete's insurance company?
Your answer
What is the athlete's policy number?
Your answer
What is the name of the policy holder?
Your answer
By typing my name in the below box, I acknowledge that I have provided the most accurate information possible concerning my son or daughter.
Your answer
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