Emergency Contact Form
Email *
Name of Athlete *
Date of Birth *
MM
/
DD
/
YYYY
Grade *
Emergency Contact Info
Primary Contact Name *
Primary Contact Relation
 *
Primary Contact Cell #   *
Secondary Contact Name: *
Secondary Contact Relation
 *
Secondary Contact Cell # *
Preferred Hospital *
List ALL allergies or medical issues we should be aware of including things like asthma. *
The undersigned gives their consent for the athletic trainer, first responder or coach too apply first aid treatment until parent/guardian or physician can be contacted or seen. We also give consent to secure medical/ambulance services in case parent can not be reached.
Parent Electronic Signature *
A copy of your responses will be emailed to the address you provided.
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