Everett Public Schools
Athletic Emergency Information
In the event of a medical emergency, medical personnel may need to know the following information. This form is to be completed prior to the start of each sports season. Please print legibly.
Athlete’s Name DOB_____________ Age__________
Address Grade_________
Parent/Guardian Phone (Hm/Wk/Cell)
Parent/Guardian Phone (Hm/Wk/Cell)
Emergency Contact #1 Phone (Hm/Wk/Cell)
Emergency Contact #2 Phone (Hm/Wk/Cell)
Athlete’s Physician Phone
Insurance Co. Policy Holder’s Name
Name of Preferred Hospital
I understand that in the event of an emergency, medical personnel will provide whatever emergency treatment is necessary after all reasonable effort has been made to contact parent, legal guardian and family physician.
Parent/Guardian Signature Date
**Please complete other side**
Please complete the following. If it does not apply, write N/A:
Did you experience a significant injury during a school or non-school activity within the last year (concussion, surgery,
broken bone, etc.)? If yes, explain.
Known allergies:
Current medications:
Important medical history including diabetes, heart disease, epilepsy, etc:
Date of last tetanus shot:
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Everett Public Schools
Athletic Emergency Information
In the event of a medical emergency, medical personnel may need to know the following information. This form is to be completed prior to the start of each sports season. Please print legibly.
Athlete’s Name DOB_____________ Age__________
Address Grade_________
Parent/Guardian Phone (Hm/Wk/Cell)
Parent/Guardian Phone (Hm/Wk/Cell)
Emergency Contact #1 Phone (Hm/Wk/Cell)
Emergency Contact #2 Phone (Hm/Wk/Cell)
Athlete’s Physician Phone
Insurance Co. Policy Holder’s Name
Name of Preferred Hospital
I understand that in the event of an emergency, medical personnel will provide whatever emergency treatment is necessary after all reasonable effort has been made to contact parent, legal guardian and family physician.
Parent/Guardian Signature Date
**Please complete other side**
Please complete the following. If it does not apply, write N/A:
Did you experience a significant injury during a school or non-school activity within the last year (concussion, surgery,
broken bone, etc.)? If yes, explain.
Known allergies:
Current medications:
Important medical history including diabetes, heart disease, epilepsy, etc:
Date of last tetanus shot:
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