Saint Robert Parish Athletics
ATHLETICS MEDICAL INFORMATION


Child's Last Name


First Name


Birth Date

Address (street number, name, apt #)


Grade

City


Zip Code


Home Phone Number

Mother / Guardian


Work Phone Number

Father / Guardian


Work Phone Number

In the event of an apparent serious illness or accident when I cannot be reached, I wish one of the following persons to be notified by telephone. They are authorized to act in my absence regarding decisions to provide medical care to my child as identified above.

Name:

______________________________

Relationship:

_________________


Address:

______________________________

Phone #:

(_____) __________

Name:

____________________________

Relationship:

_________________


Address:

____________________________

Phone #:

(_____) __________


In case of an emergency, when my emergency contacts or I cannot be reached, I give my permission to obtain or administer whatever medical services should be necessary. I agree to inform the coach in writing should my child be on medication during any game or practice.

______________________________________________________

Parent / Legal Guardian

______________________________________________________

(_____) __________

Physician Name

Phone Number

______________________________________________________

(_____) __________

Dentist Name

Phone Number

Please describe any allergies or allergic reactions:


Please list any medical perscriptions: