Fillable Insurance/contact Information & Travel Card Template printable pdf download

INSURANCE / CONTACT INFORMATION

To be completed by Parents

Student’s Name: _______________________________________ Date of Birth: ___________ Age: ______

Last

First

M.I.

Address: ___________________________________________________ Hm Phone: ________________

Street

City

Zip

Name of Parent(s)/Guardian(s): ________________________________________________________________

Last

First Name(s)

Fathers Place of Employment: _________________________________________________ Wk: Phone: ____________________

Cell Phone: _____________________

Mother’s Place of Employment: ________________________________________________ Wk Phone: ____________________

Cell Phone: _____________________

Name of Insurance Company: __________________________________________________ Phone: ______________________

Certificate/Policy Number:_______________________________________ Group Number: ___________________

Allergies (medication, etc): ____________________________________________________________________________________

Any medication taken routinely: _______ NO, ________ YES, Explain: ________________________________________________

Date of last Tetanus Immunization: ___________________

Name of relative/friend who can be contacted if parent/guardian cannot be reached –

Name: ____________________________________ Relation: _________________ Phone: _______________

Name _____________________________________ Relation: _________________ Phone: _______________

TRAVEL CARD

INFORMED CONSENT

Student’s Name: ____________________________________________________________ Date of Birth: _____________________

I hereby give my consent for the above student to compete in Greater Houston Catholic Athletic Association (GHCAA) approved sport, and travel

with the coach or other representative of the school on any trips. It is also understood that even though protective equipment is worn by the student

whenever needed, possibility of an accident still remains. Neither the GHCAA nor Archdiocese of Galveston-Houston nor Our Lady Queen of Peace

Catholic School assumes any responsibility in case an accident occurs.

If, in the judgment of any representative of the school, the above student should need immediate care and treatment as a result of any injury or

sickness, I do hereby request, authorize, and consent to such treatment as maybe give to said student by any physician, athletic trainer, nurse,

hospital, or school representative and do hereby agree to indemnify and save harmless the school and any school representative from any claim by

any person whomsoever on account of such care and treatment of said student.

Authorized school personnel (athletic trainer, coach, nurse, principal) of the Archdiocese of Galveston-Houston is hereby given my consent to

administer non-prescription medication to the above named student. Further consent is hereby given to administer prescription medication to the said

student when prescribed by his/her personal physician. Additionally, the parent/guardian and student signature below gives authorization that is

necessary for the school district, its athletic trainers, coaches and associated physicians to share information concerning medical diagnosis and

treatment of the above named student.

______________________________________________________________________

Date: ___________________________

Parent/Guardian Signature

______________________________________________________________________

Date: ___________________________

Witness

Insurance/contact Information & Travel Card Template

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