Emergency Information Form
ADVERTISEMENT
1Gatesville Independent School District
University Interscholastic League
Emergency Information Form
Please Print Except for Signatures
th
th
Name__________________________________________________ Grade: 7
/ 8
/Fr /So /Jr /Sr Birthdate_________________
Parent/Guardian: (father)_____________________________________ (mother)________________________________________
Home Phone____________________________________Work Phone__________________________________________________
Cell Phone____________________________________________________
Address________________________________________________________________________________
City______________________________________________ State______________________ Zip Code______________________
Known Allergies (drug,food,insect,etc…)_________________________________________________________________________
Special Medical Problems_____________________________________________________________________________________
Medications (inhaler, insulin, etc.)____________________________________________________________________________
Emergency Contact Name: ___________________________________________________________
Relationship:__________________ Phone:_____________________
PRIVATE (PRIMARY) INSURANCE
Co. Name____________________________________________ Pre-authorization phone #________________________________
Insurance Company Address___________________________________________________________________________________
City______________________________________________ State______________________ Zip Code______________________
Name of Insured______________________________________________________SSN__________________________________
Group#______________________________Policy#___________________Other#______________________________
My son / daughter is covered by the above insurance policy. ___________Yes______________No
Parent / Guardian Consent to Treatment of Student-Athlete
I,______________________________________________, the undersigned parent/guardian of
_______________________________________,
Name of Student
A minor, do hereby authorize the Gatesville ISD athletic trainer or school representative on my behalf to consent to
any medical treatment deemed necessary by any licensed physician / surgeon in the event of illness or injury to the above
named minor.
I give permission to Gatesville Independent School District to use and disclose any medical information necessary for
the above student to receive the most appropriate treatment. I also give permission to Gatesville Independent School District
to use and disclose medical information for the above student for the purposes of ensuring that quality care is delivered.
This consent to treat is intended to cover any illness or injury sustained while participating in any school athletic
competition or practice, on or off campus, and while traveling to and from the event.
If, in the judgment of any representative of the school, the above named student needs immediate care and treatment
as a result of any injury or sickness, I do hereby request, authorize, and consent to such care and treatment as may be given to
said student by any physician, trainer, nurse, hospital, or school representative; and I 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. I hereby authorize any hospital, which has provided treatment to the above named student to
surrender custody of that student to the athletic trainer or school representative upon completion of treatment.
These authorizations shall remain effective until the end of the 2016/2017 school year.
__________
________________________
Date
Parent/Guardian Signature
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business