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Emergency Contact Card
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* Indicates required question
Student First Name
*
Your answer
Student Last Name
*
Your answer
Building
*
Choose
North Hall
South Hall
Room
*
Your answer
Student Phone
*
Your answer
Student Email
*
Your answer
Sport
*
Choose
Baseball
Basketball (Men's)
Basketball (Women's)
Bowling (Men's)
Bowling (Women's)
Cross Country (Men's)
Cross Country (Women's)
ESports
Golf (Men's)
Golf (Women's)
Hockey
Softball
Soccer (Men's)
Soccer (Women's)
Track & Field (Men's)
Track & Field (Women's)
Wrestling
Non Athlete
Emergency Contact 1
First Name
*
Your answer
Last Name
*
Your answer
Relationship to Student
*
Choose
Parent
Legal Guardian
Sibling
Other Relative (Aunt, Uncle, Cousin, Grandparent)
Family Friend
Partner
Other
Phone
*
Your answer
E-Mail
*
Your answer
Emergency Contact 2
First Name
*
Your answer
Last Name
*
Your answer
Relationship to Student
*
Choose
Parent
Legal Guardian
Sibling
Other Relative (Aunt, Uncle, Cousin, Grandparent)
Family Friend
Partner
Other
Phone
*
Your answer
E-Mail
*
Your answer
Medical Information
Food Allergies
*
Eggs
Fish
Milk
Not Applicable
Peanuts
Sesame
Shellfish
Soy
Tree Nuts
Wheat
Other
Required
Please list the specific food if you selected "Other."
Your answer
Environmental Allergies
*
Cigarette Smoke
Cockroaches
Dander
Dust
Dust Mites
Grass
Mold
Pets
Pollen
Saliva
Weeds
Other
Required
Please list the specific environmental allergy if you selected "Other."
Your answer
Medication Allergies
*
Antibiotics (Amoxicillin, Penicillin, Tetracycline)
Antihistamines
Anti-Seizure Drugs
Aspirin
Insulin
NSAIDS (Ibuprofen, Naproxen)
Muscle Relaxers
Not Applicable
Sulfa Drugs
Other
Required
Please list the specific medication if you selected "Other."
Your answer
Do you require an epinephrine shot for any of your allergies?
*
Choose
Yes
No
If so, where do you keep your epinephrine shot?
Your answer
Do you have a cardiac or heart condition?
*
Choose
Yes
No
If you experience heart attack symptoms or go into cardiac arrest, what actions can our staff take to help you?
Your answer
Do you have a condition that may causes seizures?
*
Choose
Yes
No
If you have a seizure, what actions should our staff take to help you?
Your answer
Do you have asthma?
*
Choose
Yes
No
If so, where do you keep your inhaler(s)?
Your answer
If you have an asthma attack, what actions should our staff take to help you?
Your answer
Do you have diabetes or hypoglycemia?
*
Choose
Yes
No
If your blood sugar begins to drop, what actions can our staff take to help you?
Your answer
If you have any other serious medical condition that we should know about, please list them in the box below along with what our staff can do to help. If you do not, please put N/A.
*
Your answer
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