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