ATHLETE EMERGENCY INFORMATION CARD

South Burlington High School

Name: __________________________________________ Class/Yr. of Graduation: _____________

Address: _________________________________________________________________________

City/Zip Code: _______________________________________ Date of Birth: ___________________

Parent (#1) Name: ________________ Home Ph: _____________ Work Ph: ____________________

Parent (#2) Name: ________________ Home Ph: _____________ Work Ph: ____________________

Cell Phone:_______________ Family MD:__________________________ MD Phone: _____________

Allergies/Medical Conditions: __________________________________________________________

Medications: __________________________________________________________________________

Other Emergency Contact: _________________________ Relationship:________________________

Home Phone: ___________________ Work Phone: ____________________________________

Health Insurance Co:________________________________ Policy #:___________________________

Parent/Guardian Authorization: If I cannot be reached in an emergency, I hereby consent for a qualified physician or surgeon to examine, diagnose and to prescribe or perform treatment, including surgery, that is deemed advisable for the welfare of the above-named particiapnt.

Parent/Guardian Signature:______________________________________________

Date: _______________________ Denise Alosa, ATC (652-7507)