Athlete Emergency Care Information Form printable pdf download

Alexandria City Public Schools

Athlete Emergency Care Information

School Year: _____________-_____________

Sport(s)_________________________________________________________________________

Athlete Name:

__________________________________________

____________________________________

Gender: M / F

(last)

(first)

Date of Birth: ______/______/_______

Grade: ___________

Name of School: _______________________________________________

Parent/Guardian (#1) Name:_____________________________________________ Relation to athlete:____________________________

Parent/Guardian (#2) Name:_____________________________________________ Relation to athlete:____________________________

With whom does the athlete live?______________________________________ Home phone # ___________________________________

Home Address: _______________________________________________________________________________________________________________

Guardian (#1) work phone: ______________________________________ Cell phone: _____________________________________________

Guardian (#2) work phone: ______________________________________ Cell phone: _____________________________________________

EMERGENCY CONTACTS

In case of an emergency, every effort will be made to contact a parent or guardian first. If above parents/guardians cannot

be reached in a timely manner, please identify someone else who may make decisions for the athlete until the parents can

be reached.

Designated Contact:

Name:________________________________________ Relationship:__________________________ Phone #______________________________

Designated Contact:

Name:________________________________________ Relationship:__________________________ Phone#______________________________

ATHLETE EMERGENCY MEDICAL INFORMATION

Current Health

Allergies: Y / N

EpiPen: Y / N

Inhaler: Y / N

Diabetes: Y / N

(circle yes or no)

Prescription Meds: Y / N

Hemophila: Y / N

Seizures: Y / N

Vision Impairment: Y / N

If you answered YES to any above, please give details: ___________________________________________________________________

_________________________________________________________________________________________________________________________________

Other current health issues or conditions: ________________________________________________________________________________

Previous health issues or conditions:______________________________________________________________________________________

ATHLETE INSURANCE

NONE

(if the student-athlete is not covered under any insurance plans, please check here)

Insurance Company: ______________________________________________________ Phone #_________________________________________

Policy #____________________________________________________ Holder Name:___________________________________________________

PLEASE READ AND SIGN BELOW

 In an emergency, when I cannot be reached, the school has my permission to have my child transported to the

nearest hospital emergency room. Furthermore, I authorize the hospital and its staff to provide treatment

which is deemed necessary for the well-being of my child.

(This form will be readily accessible to the coaches, athletic

trainers, and/or team sponsors, and will be sent to the hospital with the student athlete if an emergency arises)

 I have read and reviewed the “Concussion Information for Parents and Students” handout with my child. I am

aware that there is risk of head injuries in any sport, and that my son/daughter may sustain a concussion

during the course of their athletic season. I understand the seriousness of traumatic brain injuries and that it

requires proper management from an appropriate healthcare professional.

Guardian Name

:__________________________________________ Signature:____________________________________________ Date:___________

(print)

Athlete Name

:____________________________________________ Signature:____________________________________________ Date: ___________

(print)

Athlete Emergency Care Information Form

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