Athletic Activities Packet (Page 2 of 4) in pdf

MEDICAL INSURANCE & EMERGENCY AUTHORIZATION FORM

Name of Athlete ________________________________ Grade __________

Address ________________________________________________________

INSURANCE:

Option 1 _____ My son/daughter will enroll in the Student Accident Insurance Program offered through Bremerton School District.

Option 2 _____ My child is covered by the insurance listed below and I will continue to keep it in force throughout the sports season. If there are any changes

in this status, I will contact the school to inform them of changes in insurance. The high school principal or designee is authori zed to contact the company

named below to verify coverage limitations. I accept full responsibility for the cost of treatment of any injury that my son/daughter may suffer while taking

part in the program.

Name of Company Providing Insurance: __________________________________________________

Policy or Group #_____________________________________________________________________

Parent/Guardian Signature _________________________________________ Date _______________

EMERGENCY AUTHORIZATION

As parent or legal guardian, I authorize the team coach or trainer, or in their absence, a qualified physician to examine the above named student, and in the

event of injury to administer emergency care and to arrange for any consultation by a specialist, including a surgeon, he dee ms necessary to insure proper

care of any injury. Every effort will be made to contact parent or guardian to explain the nature of the problem prior to any involved treatment. I hereby

give permission to the school to contact emergency transportation necessary at parent/guardian expense.

Name of

Parent/Guardian:______________________________Email:__________________________________

Home Phone: __________________ Cell Phone: ___________________ Work Phone:_____________

Emergency Contact:___________________________________________ Phone:__________________

Physician:____________________________________________________ Phone: _________________

If your physician is not available, will you accept the physician taking calls: ______Yes ______ No

If no:

Alternate Physician:____________________________________________ Phone: ________________

Hospital Preference: ______Harrison Hospital

______ Navy Hospital

______ Other

History of injuries and/or surgeries: _____________________________________________________

Allergies to drugs (please list): __________________________________________________________

I accept full responsibility for the cost of treatment for any injury, which my child may suffer while

taking part in the athletic and activities programs at Bremerton School District.

Parent/Guardian Signature:__________________________________________ Date _______

Athletic Activities Packet Page 2

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