HEALTH HISTORY

Family Doctor________________________________ Phone______________________

Hospital_____________________________________ Phone______________________

Yes No Does the student wear any of the

Following while competing?

Kidney Injuries ___ ___

Heart Condition ___ ___ Yes No

Diabetes ___ ___

Asthma ___ ___ Glasses ___ ___

Allergies ___ ___ Contacts ___ ___

Artificial

Dental devices ___ ___

Other ___ ___

If yes, explain:

Other medical problems a coach or physician should be aware of:

HEALTH HISTORY

Family Doctor________________________________ Phone______________________

Hospital_____________________________________ Phone______________________

Yes No Does the student wear any of the

Following while competing?

Kidney Injuries ___ ___

Heart Condition ___ ___ Yes No

Diabetes ___ ___

Asthma ___ ___ Glasses ___ ___

Allergies ___ ___ Contacts ___ ___

Artificial

Dental devices ___ ___

Other ___ ___

If yes, explain:

Other medical problems a coach or physician should be aware of:

Student Name_________________________ Address_____________________ Home Phone__________

Date of Birth:____________ Insurnace___________________________ Insurnace #________________

Father’s Name_______________________________ Father's Work#_____________________________

Mother’s Name______________________________ Mother’s Work#_____________________________

In case none of the above can be reached, please notify:

Name________________________________ Home Phone________________ Work Phone__________

Permission For Medical Treatment

In the case of an emergency requiring medical attention, I hereby grant permission to a physician or other hospital personnel to attend my son/daughter. I expect every effort will be made to contact me in order to receive my specific authorization before any treatment or hospitalization is undertaken

______________________________________

Parent/Guardian

Student Name_________________________ Address_____________________ Home Phone__________

Date of Birth:____________ Insurnace___________________________ Insurnace #________________

Father’s Name_______________________________ Father’s Work#_____________________________

Mother’s Name______________________________ Mother’s Work#____________________________

In case none of the above can be reached, please notify:

Name________________________________ Home Phone________________ Work Phone___________

Permission For Medical Treatment

In the case of an emergency requiring medical attention, I hereby grant permission to a physician or other hospital personnel to attend my son/daughter. I expect every effort will be made to contact me in order to receive my specific authorization before any treatment or hospitalization is undertaken.

____________________________________

Parent/Guardian