ZION-BENTON TOWNSHIP HIGH SCHOOL

Athlete Emergency Information

Athlete's Name Year in School ( circle one) 9 10 11 12

Sport(s) Participating In (list all) _________________________________________________________________________________

Age _____ Birthday __________ Social Security # _____-_____-_____Home Phone _____________________________________

Home Address w/City & Zip Code ________________________________________________________________________________

Father's Name _____________________________________                              Mother's Name _____________________________________

Father's Work Phone ________________________________                              Mother's Work Phone ________________________________

Emergency Name and # if Parents are not available:

Name _____________________________________Phone _____________________________________

Athlete wears contacts? _____YES ______NO           Insurance Carrier _____________________________________

Medication(s) being taken and reason _________________________________________________________________________________

________________________________________________________________________________________________________________

Allergies (Medication, Insect bites, Tape adhesives, etc.____________________________________________________________________

________________________________________________________________________________________________________________

Previous injuries & dates of same (fractures, dislocations, concussions, etc.)____________________________________________________

________________________________________________________________________________________________________________

Additional information pertinent to athlete's health (asthma, diabetes, heart conditions, seizures, etc.) ._______________________________

________________________________________________________________________________________________________________

ATHORIZATION FOR MEDICAL TREATMENT

I give my consent and permission to any supervising coach of any sport in which my child is or may be participating in at Zion-Benton Township High School, and the right, on my behalf and in my stead, to arrange for a licensed and certified physician and/or trainers to render and provide immediate treatment to my child as

to injuries that may be sustained by my child while participating in such sport, whether directly or indirectly, and whether sustained during practice or in active interscholastic competition, where such injuries consist, of, but are not limited to sprains, strains, minor fractures, dislocations, lacerations, contusions, abrasions, and similar injuries, and all without necessity of any further or additional express authorization by me, other than for this authorization. My above permission and consent also extends to the right of any supervising coach or school personnel to arrange for immediate medical treatment by a licensed or certified physician and/or trainer, and for them to apply such emergency techniques as may be necessary to my child where the same, in their judgment, is deemed appropriate by reason of any injury sustained by my child, and where the same, in their judgment, is deemed reasonably necessary to preserve the life or limb of my child.

Name of child to whom the authorization extends.________________________________________________________________________

Signature of parent/guardian .______________________________________________________________Date____________________