Emergency Medical Form
Name
________________________________________________ SS# ______________
Address
________________________________________________________________
Phone
__________________________ Age ________ Birthdate
___________________
Father’s Name or Day Phone __________________
Legal Guardian
_______________________________ Eve Phone _________________
Mother’s Name or Day Phone _________________
Legal Guardian ________________________________
Eve Phone _________________
Doctor
_______________________________________ Phone ____________________
Address
________________________________________________________________
Hospital
______________________________________ Phone ____________________
Insurance Yes No Name of Company
________________________________
Group #
_____________________________ I.D.#
______________________________
Other Person to Contact
__________________________ Phone ____________________
Does student have any special
medical problems Yes No
If yes, please explain
______________________________________________________
________________________________________________________________________
Is student taking any
medication Yes No
If yes, please specify
______________________________________________________
Is student allergic to any
drugs Yes No
If yes, please specify
______________________________________________________
When did student receive her
last tetanus shot _____/_____/_____
In case of illness, accident,
or other emergency involving this student, the principal or coach is authorized
to act on my behalf if I cannot be contacted.
__________________________________ OR __________________________________
Signature of Father/Guardian Signature of Mother/Guardian
Date ______________________________ Date _____________________________