CROOKSVILLE HIGH SCHOOL ATHLETICS Emergency Medical Authorization
Athlete Name:	Age:	Upcoming Grade:	Year:
Purpose: To enable parents to authorize emergency treatment for their children who become ill or injured while under school authority and when a parent cannot not be reached.
Emergency Contact Numbers:
Parent / Guardian Name:	Phone #:	Cell/Work #:
Parent / Guardian Name:	Phone #:	Cell/Work #:
Other Emergency Contact:	Phone #:	Cell/Work #:
I hereby give my consent for (1) the administration of any treatment deemed necessary by current athletic trainer for my child.
(Preferred General Practitioner) Doctor:	MD	DO
(Preferred) Dentist:
In the event that the preferred practitioner is unavailable, treatment can be performed by another licensed physician or dentist.
(2) The transfer of the child to: (Preferred) Hospital:
Or any hospital reasonably accessible
Medical History:
PLEASE SPECIFY IF CHILD IS ALLERGIC TO A MEDICATION OR IS ON ONE CURRENTLY
Allergies:
Medications Taking:
Any Medical Conditions:
Any Past Orthopedic Injuries:
Insurance:
I,	(parent/guardian) of	(athlete), state
that I have/will have proper medical and surgical insurance to cover any and all accidents or medical injuries during
2	- 2	(year) sport seasons: covering practices, scrimmages, games, or any other activity related with
the participation in athletics at Crooksville Schools.
MUST HAVE!!!
Company Name:	Policy Number:
Print Name:
Signature of Parent/Guardian:	Date:
Mailing Address:	Home Phone #: