(This information will not be shared)
Cheerleaders name_________________________________________________________________________
Phone numbers parents/guardian can be contacted for emergencies
Home_____________________ (M)Work____________________(D)Work__________________
(M)Cell___________________(D)Cell_________________
(M)Pager__________________(D)Pager__________________
Family member name and #___________________________
Friend�s name and #____________________________________________________
Please list any information you feel we should know about your cheerleader.
First Aid Information
Please circle each of the following your cheerleader MAY take in
case of illness.
Tylenol-junior Tylenol-regular Tylenol-extra strength
Motrin Advil
Peptobismol Imodinm AD-tablets Emetrol
Sportscreme Neosporin Band-Aids
Cough Drops�regular/not prescription
Please list any medication that your cheerleader may bring with them to practice or on trips.
Medicine Dosage
_________________________________ ________________________
_________________________________ ________________________
I give the administrators/chaperones permission to administer the above medications to
_________________________. Signed _________________________
EMERGENCY TREATMENT PERMISSION:
I give my permission to authorize EMERGENCY MEDICAL TREATMENT for my cheerleader in the event that I am unable to be reached.
Signed______________________________________ Dated__________________________
Insurance information:
Carrier ____________________________Plan number__________________
Policy number ______________________Phone number_________________