CENTERVILLE SCHOOL #215

MEDICAL EMERGENCY AUTHORIZATION FORM

TO BE COMPLETED BY PARENT AND RETURNED TO SCHOOL PRINCIPAL’S OFFICE

Name of Student Athlete

As Parent or Legal Guardian, I authorize the team physician or, in his absence, a qualified physician to examine the above-named student and in the event of injury to administer emergency care and to arrange for any consultation by a specialist, including a surgeon, he deems necessary to insure proper care of any injury. Every effort will be made to contact parent or guardian to explain the nature of the problem prior to any involved treatment.

Name Date

(Signature of Parent or Guardian)

Parent’s Home Phone Busincess Phone

Emergency Contact Person

Name Phone

Relationship of contact person

Family Physician’s Name _____________________________ Phone

Name of Family Insurance Company ________________________ Policy #

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FOR SCHOOL USE ONLY:

Completed Form Received ______________________ ______________________________ Date Name

Duplicate Copy Distributed to _____________________________________________________

on ______________

Date

Insurance coverage by parents Yes_____ No_____ Unknown_____

One copy filed in Student Permanent Record:________________ By_________________

Date Name