Microsoft word - a-b form_1.doc

Dear Parent or Guardian: The following forms are for use if we cannot contact you in the case of an emergency. Form A is the information the hospital requires prior to treatment. This information will be held in strict confidence. The forms will be taken to all games and practices. The permission form (Form B) will be used only if the hospital cannot contact you. Help us provide the best health care for our student-athletes and your children by filling it out completely. If you have any questions, don’t hesitate to ask. Sincerely, Ellen Benham Name__________________________________Age______Sex______Birth Date _____/_____/_____ Address___________________________________________________________________________Home Phone________________________________________________________________________ Parent or Guardian Name_______________________________________Cell Phone_______________ Employer of Parent or Guardian__________________________________________________________ Address of Employer___________________________________________Phone__________________ InsuranceCompany____________________________________________________________________ Policy #_________________________________Name of Policy Holder__________________________ Hospital Requested________________________Physician Requested____________________________ Is student allergic to any medication? Yes / No What?_______________________________________ Is student currently taking any medication? Yes / No What?___________________________________ Any food allergies or symptoms?__________________________________________________________ Do these allergies require Epipen or Benadrly? Yes / No. If yes, circle one. Severe Bee Sting Alergy? Yes / No Does student requires use of Epipen / Benadryl? Yes / No If yes, circle one. Other________________ Asthma? Yes / No If yes, check one: Mild______ Moderate ______ Severe _______ Exercise Induced _______________ Date of last episode_________________________Asthma medication? Yes / No What?_____________ Seizures? Yes / No Date of last seizure_____________________________ Type__________________ Diabetes? Yes / No Does the student require the use of Insulin Pump______ Pen______ Injections_____ Other____________ Any other medical conditions the coach should be made aware of?________________________________ Last TetanusToxin______________________________________________________________________ *Emergency Contact Name______________________________________Phone____________________ Relationship to Student__________________________________________________________________ *Emergency Contact Name______________________________________Phone____________________ Relationship to Student__________________________________________________________________ (Please continue on other side) I give permission for my child to participate in interscholastic sports. I understand the risks involved in participation in interscholastic sports. I give my permission for the Bristol coaching staff to seek medical treatment for ____________________ in case of injury or illness that occurs while participating in school sponsored activities if I cannot be reached to give my consent to emergency personnel. __________________________ Signature of Parent or Guardian

Source: http://www.bristol.k12.ct.us/uploaded/Northeast_MS/athletics/Intramural_emergency_form.pdf