Collinsville High School Athletics Information Sheet printable pdf download

COLLINSVILLE HIGH SCHOOL ATHLETICS INFORMATION SHEET

STUDENT INFORMATION:

FULL NAME: ____________________________________________

Birth Date: _____________________

GRADE:

SPORT: ________________________

PHONE: ______________________

HOME ADDRESS: ______________________________________________________________________________________

(Street, City, State, & Zip)

MEDICAL INFORMATION:

ALLERGIES: __________________________________

MEDICATIONS: ______________________________

EXISTING MEDICAL CONDITIONS/CONCERNS: ___________________________________________________________

EMERGENCY CONTACT INFORMATION:

RELATIONSHIP:

____________________

FULL NAME: __________________________________________________________________________________________

WORK PHONE: __________________________________

CELL PHONE: ________________________________

(Include Area Code)

UNDERSTANDING OF CONCUSSION IN SPORTS

I have read the concussion info at:

I understand the

importance of recognizing the symptoms of a concussion. I understand and accept the responsibility of reporting such symptoms to

the proper school and medical professionals.

PARENT/GUARDIAN INITIALS___________________

STUDENT INITIALS___________________

MEDICAL AUTHORIZATION

TO WHOM IT MAY CONCERN:

I, the undersigned, being the parent or legal guardian of __________________________________ do hereby grant to any hospital,

emergency center, doctor, nurse, and/or paramedic authorization to grant treatment to my child, when accompanied by or escorted to

the treatment facility by a teacher, coach, teacher’s aide, principal, or any member of Collinsville Unit District #10 Board of

Education.

Further, should the attending physician determine after examination that life-saving surgery or other life saving

procedures might be necessary; permission is hereby extended to the above parties to grant it. Additionally, I agree to hold harmless

such personnel and the Collinsville Unit District #10 Board of Education by action of granting said permission.

___________________________________________________

___________________________

Signature of Parent/Guardian of Above-Named Child

Date

Collinsville High School Athletics Information Sheet