Emergency Medical Authorization Form
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2SPORT: _______________
SEASON:______________
SCHOOL YEAR:_________
WOODRIDGE ATHLETIC DEPARTMENT
EMERGENCY MEDICAL
AUTHORIZATION FORM
STUDENT: __________________________________________
GRADE: ____
ADDRESS: __________________________________________
CITY: __________________________ ZIP: ___________________
HOME PHONE: _____________________________________
PURPOSE: To enable parents and guardians to authorize the provision of emergency treatment
for children who become ill or injured while under school authority, when parents or guardians
cannot be reached.
RESIDENTIAL PARENT OR GUARDIAN:
MOTHER’S INFORMATION:
FATHER’S INFORMATION:
Name: ______________________________
Name: ______________________________
WORK PHONE: ____________________________
WORK PHONE: ____________________________
CELL PHONE: _____________________________
CELL PHONE: _____________________________
EMAIL:____________________________________
EMAIL:____________________________________
LIST STUDENT MEDICAL CONTITIONS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Parent category: Business