IHSA - Emergency Information Form - Athletics and Activities
Coaches and sponsors carry this with them at all events in case the parent/guardian is not able to attend and there is an emergency.
Email address *
Student name *
Your answer
Grade Level *
Parent/Guardian name *
Your answer
Emergency Contact Number *
Your answer
2nd Emergency Contact Number *
Your answer
Physician Name *
Your answer
Physician number *
Your answer
Specific health Conditions (if any. if none please list n/a) Asthma, heart conditions, etc... *
Your answer
If you and the physician of choice (as indicated above) can not be reached in case of an emergency and if, in the judgement for the school authorities, immediate medical and/or hospital attention is indicated, do you authorize responsible school authorities to send your child (properly accompanied) to an available hospital or physician? *
Required
Insurance Information. As the parent/guardian, I wave any claim for liability against the Athletic Co-op, including employees and representatives, and release them from liability in connection with this activity. *
Required
Insurance Carrier *
Your answer
Policy Number *
Your answer
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