Required Medical Info

* indicates a required answer.

Please fill out the following Required Medical Information once for your child for the current school year:

1.*

Current Term or Season:

2. *

Participant's Name:

3.*

Is your child currently taking any medications?

 (1 required)
Yes No
4. 

If yes, list all medications your child is currently taking:  

5. *

List known allegeries (if none indicate "none"):

6.

Date of last physical:

7.

Preferred hospital:

8. *

Physician Information:
     Name:

9. *

     Office Address (include city/state/zip):

10. *

     Phone Number:

11. *

Insurance Information:
     Provider:

12. *

     Policy Number:

Emergency Contact Information: (other than a parent)

13. *

     Name/Relationship:

14. *

     Home Phone:

15.

     Cell phone:

16.*

In the event of any injury or emergency, if I or my emergency contact cannot be notified, I authorize the individual(s) in charge to obtain emergency medical treatment for my child as deemed necessary by competent medical personnel. I understand that I am fully responsible for any and all charges incurred in the event of such treatment.

17. *

Name

18. *

Date