Medical Card For Athlete - Montgomery County Public Schools Page 2
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1
2MEDICAL CARD FOR ATHLETE
Family Physician:
Physician #:
Hospital Preference:
Date of Last
Tetanus Shot:
Allergies:
Student Self-Carries
EpiPen: □ Yes □ No
Medicine Administered on the Field:
INSURANCE INFORMATION:
Does your son/daughter have medical insurance?
□ Yes
□ No
If Yes, Name of Insurance Company: ____________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
RELEASE FOR TREATMENT:
I hereby give permission to the attending physician or hospital to administer
appropriate medical treatment in the event I cannot be reached.
Signature
Parent/Guardian:
Date
This card must be kept on file in the medical kit for each sport and should be
available at all practices and contests. It must accompany the athlete to the doctor
or hospital when emergency medical attention is required.
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