Athletic Emergency Form Season * Year * Participant's Name * Participant's Gender Participant's Birthdate * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Parent / Guardian Information Parent / Guardian 1 Information * First Name Last Name Parent / Guardian 1 Phone * (###) ### #### Parent / Guardian 1 Email Check box if authorized to pick up participant Parent / Guardian 2 Information First Name Last Name Parent / Guardian 2 Phone (###) ### #### Parent / Guardian 2 Email Check box if authorized to pick up participant Emergency Contact Emergency Contacts must be persons other than parents/guardians listed above Emergency Contact's Name * First Name Last Name Emergency Contact's Phone * (###) ### #### Relationship to Participant * Check box if authorized to pick up participant Emergency Contact's Name First Name Last Name Emergency Contact's Phone (###) ### #### Relationship to Participant Check box if authorized to pick up participant Emergency Contact's Name First Name Last Name Emergency Contact's Phone (###) ### #### Relationship to Participant Check box if authorized to pick up participant Authorized Pickup Information If any additional people are authorized to pick up your participant, please complete this section. (Optional) Name First Name Last Name Phone (###) ### #### Relationship to Participant Name First Name Last Name Phone (###) ### #### Relationship to Participant Name First Name Last Name Phone (###) ### #### Relationship to Participant Medical & Health History Please check all that apply. Include specifics where applicable. Illnesses Heart defect/disease Musculoskeletal Disorders Bleeding/Clotting Disorders Type 1 Diabetes Type 2 Diabetes Seizures* * Please use space below to specify type and frequency of the seizures: Other* * Please use the space below to specify: Allergies – include specifics Insect Bites/Stings Pollen Latex Medicines/Drugs Nuts Milk Food (specifics) Other Please explain type of allergy and severity of reaction: Others/Special Needs Wears Contacts/Glasses Fainting Ear Problems/Tubes Hearing Impairment Emotional Behaviors ADD/ADHD Medicated Non-Medicated Nose Bleeds Are there any special family circumstances we should be aware of (i.e. divorce, recent move, etc.)? I give my permission for my child to receive necessary health care and emergency medical treatment. This Athletic Emergency Form is complete and accurate. I will not allow my child to attend if they become exposed to any contagious disease, or if for any reason, I do not consider my child to be in good physical condition. Parent / Guardian Full Name * This is your electronic signature Date * Today's Date MM DD YYYY Thank you!
