Glacial Drumlin School Athletic Department Emergency Form
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1GLACIAL DRUMLIN SCHOOL
ATHLETIC DEPARTMENT
EMERGENCY FORM
Dear Parent/Guardian:
The authorization will help assure that your child will begin receiving emergency medical treatment should he/she have a
broken bone or any other non-life threatening situation, and you are not able to be contacted to authorize medical
treatment for your son/daughter. Please fill out the lower portion and have your son/daughter return to his/her coach so
they can keep this information on file at practices and games in case of an emergency.
Thank you for your cooperation.
Authorization for Emergency Transportation and Treatment
I authorize school personnel to transport my son/daughter to a physician’s office and/or emergency room for treatment in
the event that emergency medical care is needed while he/she is involved in either co-curricular or extra-curricular
activities. Furthermore, I authorize the PHYSICIAN and HOSPITAL STAFF to treat my son/daughter, as they deem
.
necessary in the emergency situation
STUDENT’S NAME:
__________________________________
DATE OF BIRTH_____/_____/_____
ADDRESS:
__________________________________
GRADE: _____
CITY, STATE, ZIP:
__________________________________
PHONE: (H) ________________________
Assumption of Risk
I realize that there is a possibility that my child may suffer severe injuries, including permanent paralysis or death as a
result of participation in athletic activities
.
I have read and understand the “policies and procedures” for athletics at Glacial Drumlin, and want my child to participate.
I also give permission for the authorization stated above.
SIGNATURE OF PARENT: ____________________________DATE:____/____/_____
Emergency Contact(s)
NAME
Home phone
Cell
Work
Relationship
Parent
Parent
Emergency
Contact
Emergency
Contact
Allergy/Medication Information
Is your Son/Daughter Presently Taking any Medication:
YES
NO
If Yes, Please List Medications Here:
_________________________________________
Is Your Son / Daughter Allergic to Any Medications?
YES
NO
If Yes, Please List:
_________________________________________
Does your child have any allergies?
YES
NO
If Yes, Please List:
_________________________________________
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