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Emergency Information Card
Athlete’s name ________________________________________________________ Age ______

Address ____________________________________________________________________________

Phone ________________________________________________ S.S. #________________________

Sport ________________________________________

List two persons to contact in case of emergency:

Parent or guardian’s name ____________________________________________________________

Address ___________________________________________________________________________

Home phone _____________________________ Work phone _____________________________

Second person’s name _______________________________________________________________

Address ___________________________________________________________________________

Home phone _____________________________ Work phone _____________________________

Relationship to athlete ______________________________________________________________

Insurance co. ___________________________________ Policy # ___________________________

Physician’s name _____________________________________ Phone ______________________

IMPORTANT
Is your child allergic to any drugs? _______ If so, what? _________________________________

Does your child have any other allergies? (e.g., bee stings, dust) _________________________

Does your child suffer from _______ asthma, _______ diabetes, or _______ epilepsy?

Is your child on any medication? _______ If so, what? __________________________________

Does your child wear contacts? _______

Is there anything else we should know about your child’s health or physical condition? If yes,

please explain. _____________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

_______________________________________________________          _________________________
Signature                                                        Date

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emerg_info_card

  • 1. Emergency Information Card Athlete’s name ________________________________________________________ Age ______ Address ____________________________________________________________________________ Phone ________________________________________________ S.S. #________________________ Sport ________________________________________ List two persons to contact in case of emergency: Parent or guardian’s name ____________________________________________________________ Address ___________________________________________________________________________ Home phone _____________________________ Work phone _____________________________ Second person’s name _______________________________________________________________ Address ___________________________________________________________________________ Home phone _____________________________ Work phone _____________________________ Relationship to athlete ______________________________________________________________ Insurance co. ___________________________________ Policy # ___________________________ Physician’s name _____________________________________ Phone ______________________ IMPORTANT Is your child allergic to any drugs? _______ If so, what? _________________________________ Does your child have any other allergies? (e.g., bee stings, dust) _________________________ Does your child suffer from _______ asthma, _______ diabetes, or _______ epilepsy? Is your child on any medication? _______ If so, what? __________________________________ Does your child wear contacts? _______ Is there anything else we should know about your child’s health or physical condition? If yes, please explain. _____________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ _______________________________________________________ _________________________ Signature Date