STEM Athletics Emergency Card- Must be completed for EACH sport season
This form is to be filled out by Parent or Guardian.
Parent/Guardian: Type your full name and today's date below to acknowledge and agree to the following statement: "I attest under penalty of law, that the information given in this form is accurate and correct to the best of my knowledge. I AUTHORIZATION THE FOLLOWING FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR MY STUDENT ATHLETE." *
Your answer
Name of Athlete *
Your answer
Age of Athlete *
Your answer
Grade of Athlete *
Your answer
Athlete's Date of Birth *
Your answer
School Name *
Sport *
Your answer
Season *
Name of parent/guardian *
Your answer
Address *
Your answer
Home phone *
Your answer
Cell phone *
Your answer
Email *
Your answer
Business *
Your answer
Insurance Company and Policy # *
Your answer
Family Doctor and phone number *
Your answer
Relative #1 to be contacted in case of emergency and his/her best phone number (if parent/guardian is not availble) *
Your answer
Relative #2 to be contacted in case of emergency and his/her best phone number (if parent/guardian is not availble) *
Your answer
In the event parent, family doctor, relative, or authorized individual cannot be reached, indicate your 1st hospital preference *
Your answer
In the event parent, family doctor, relative, or authorized individual cannot be reached, indicate your secondary hospital preference *
Your answer
CARE FOR INJURED ATHLETES
F CONTACT CANNOT BE MADE WITH ANY OF THE ABOVE, THE COACH WILL USE HIS/HER BEST JUDGEMENT TO PROTECT AND ASSIST THE INJURED ATHLETE IN ACCORDANCE WITH THE FOLLOWING POLICIES: A. Caring for the athlete. B. Notifying the athlete’s parents or guardian, or if these cannot be reached, for the following directions given on athlete’s emergency card. C. In extreme cases, getting the athlete under professional care with or without family permission. D. In cases of a need for emergency rescue aid a coach should call 911. E. Complete an accident report. FOR EMERGENCY RESCUE AID - Call 9-1-1. STEM High & Academy does not provide any accident or health insurance coverage for students while participating in interscholastic athletics. It is the parent/guardian’s responsibility to provide insurance coverage for his/her child.
Parent/Guardian, type your full name below with today's date indicating you have read, understood and agree to "Care for Injured Athletes"
Your answer
Significant Health Concerns *
Your answer
Daily Medications *
Your answer
Emergency Medications *
Your answer
Consent for Athletic Conditioning, Training, and Health Care Procedures
I hereby give consent for my child to participate in school’s athletic conditioning and training program and to receive any necessary health care treatment, including first aid, diagnostic procedures and medical treatment, which may be provided by treating physicians, nurses and other healthcare providers, including Certified Athletic Trainers. The Certified Athletic Trainers have my permission to release athletic injury information about my child to the school. In the event I cannot be reached in an emergency, I hereby give permission for my child to be transported to receive necessary treatment. I understand that the Certified Athletic Trainers do research in the prevention of athletic injuries and use generalized information that does not personally identify the individual student. The Certified Athletic Trainers may use this generalized information that does not identify my student in such research.
Parent/Guardian, type your full name below with today's date indicating you have read, understood and agree to "Consent for Athletic Conditioning, Training, and Health Care Procedures" *
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of STEM School Highlands Ranch. Report Abuse - Terms of Service