Fillable Athletic Emergency Information Card Form printable pdf download

ABILENE INDEPENDENT SCHOOL DISTRICT

ATHLETIC EMERGENCY INFORMATION CARD

STUDENT’S NAME ____________________________________________________________ GRADE __________AGE ____________

HOME PHONE ____________________ ADDRESS ________________________________________________ ABILENE, TX 7960___

SOCIAL SECURITY # ______________________________________________________ DATE OF BIRTH ______________________

CELL PHONE _____________________ ALLERGIES ___________________________ CORRECTIVE LENSES: Y N GLASSES

OR CONTACTS. MEDICATIONS TAKEN ON REGULAR BASIS: ____________________________________________________

SPECIAL CONDITIONS THAT SHOULD BE KNOWN BY SCHOOL STAFF OR TEAM PHYSICIAN: ______________________

_________________________________________________________________________________________________________________

FATHER’S NAME ______________________________________ MOTHER’S NAME _______________________________________

(COMPLETE THE NEXT TWO LINES IF DIFFERENT FROM STUDENT. EMERGENCY CONTACT WILL BE PARENT WITH WHICH THE STUDENT LIVES)

FATHER’S NAME ______________________________________ MOTHER’S NAME _______________________________________

FATHER’S ADDRESS ___________________________________ MOTHER’S ADDRESS ___________________________________

FATHER’S HOME PHONE _______________________________ MOTHER’S HOME PHONE ______________________________

FATHER’S CELL PHONE ________________________________ MOTHER’S CELL PHONE _______________________________

FATHER’S EMPLOYER __________________________________ MOTHER’S EMPLOYER ________________________________

EMPLOYER’S PHONE ___________________________________ EMPLOYER’S PHONE __________________________________

PERSON TO CONTACT IN AN EMERGENCY IF PARENT’S CANNOT BE NOTIFIED:

NAME ________________________________ ADDRESS _______________________________________ PHONE _________________

RELATIONSHIP ______________________________ CELL PHONE ____________________________

I understand that the Abilene Independent School District, through its Board of Education, has voluntarily adopted a co-

insurance plan to help offset medical expenses incurred as a result of accident while participating in athletics. I understand that co-

insurance means that I must also file my personal insurance. Therefore, I am providing the following information in the event that I

cannot be contacted, and medical services are needed. I understand that any medical expenses incurred will be addressed to me and

that I will be responsible for completing proper forms necessary to file insurance claims.

NAME OF MY CHILD’S INSURANCE COMPANY _________________________________________________________________

ADDRESS OF MY CHILD’S COMPANY __________________________________________________________________________

PHONE NUMBER OF MY CHILD’S COMPANY __________________________________________________________________

IF GROUP, NAME OF EMPLOYER ______________________________________________________________________________

MY CHILD’S IDENTIFICATION NUMBER _______________________________ GROUP NUMBER ______________________

I UNDERSTAND THAT THE ABILENE INDEPENDENT SCHOOL DISTRICT, NOR ANY OF ITS EMPLOYEES, ARE

RESPONSIBLE FOR THE BILLING, FILING OF CLAIMS, NOR PAYMENTS TO ANY PROVIDER OF MEDICAL SERVICES

FOR ANY ATHLETIC INJURY. I AGREE TO ACCEPT FINANCIAL RESPONSIBILITY, IF IN THE JUDGEMENT OF ANY

REPRESENTATIVE OF THE SCHOOL, THE STUDENT NAMED ON THE REVERSE SIDE OF THIS CARD, SHOULD NEED

IMMEDIATE CARE AND TREATMENT AS A RESULT OF ANY INJURY OR ILLNESS. I DO HEREBY REQUEST,

AUTHORIZE, AND CONSENT TO SUCH CARE AND TREATMENT, AS MAY BE GIVEN SAID STUDENT BY ANY

PHYSICIAN, LICENSED ATHLETIC TRAINER, NURSE, OR SCHOOL REPRESENTATIVE, AND DO HEREBY AGREE TO

IDEMNITY AND SAVE HARMLESS THE SCHOOL AND ANY SCHOOL REPRESENTATIVE FROM ANY CLAIM BY ANY

PERSON WHOSOEVER ON ACCOUNT OF SUCH CARE AND TREATMENT OF SAID STUDENT.

PARENT/GUARDIAN SIGNATURE

DATE

Athletic Emergency Information Card Form