Cleared to Participate and Emergency Form

CLEARED TO PARTICIPATE & EMERGENCY INFORMATION FORM

Student Athlete Name:________________________________________Grade:_________ID#_________

This student has turned in the following information to the Athletic Trainer. To the best of my knowledge it is complete and accurate and this student is now cleared to begin practicing/ participating.  The Head Coach is responsible for having this document readily available for travel.

Emergency Information:

Mother’s Name:_________________________________________________________________________

Home Phone:______________________Work Phone:___________________Cell Phone:______________

Father’s Name:_________________________________________________________________________

Home Phone:______________________Work Phone:___________________Cell Phone:______________

Home Address:_________________________________________________________________________

Emergency contact (other than parent):

Name and relationship:_____________________________Home Phone:__________Cell Phone:________

Medical History:

ALLERGIES:_________________________HISTORY OF ANAPHYLAXIS:_____Y_____N

IMMUNIZATIONS UP-TO-DATE:_____Last Tetanus Immunization:________

Significant Medical History Information.  Please indicate any history of asthma, hypertension, previous head injury, unequal pupil size, etc.

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Current Medical Conditions:_________________________________________________________________________

_______________________________________________________________________________________________

Current Medications and if asthma medication please indicate if needed prior to sports:__________________________

_______________________________________________________________________________________________

Does athlete wear contact?_____Y_____N

Does athlete require eye protection while playing?_____Y_____N

Student's Primary Physician/Provider for follow-up, if necessary:____________________________________________

Address:_______________________________________________Phone:___________________________________

Hospital Preference:_____________________________1st Choice:_______________2nd Choice:________________

Insurance Provider:______________________________Policy number:______________________________________

OFFICE USE ONLY:

LLHS/VHS Athletic Trainer:____________________________________________________________________________Date:___________________

There may be other circumstance that make this student ineligible and preclude participation at this time and/or require petitioning: Foreign exchange, transfer student, grades, attendance, etc.

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