EMERGENCY INFORMATION

ATHLETE INFORMATION:

Student’s Name _______________________________________________

Date of Birth _______ ______ _______        Grade ___________

Sport(s) ___________________________________

Have you played on an ISPS athletic team in the past? [ ] No [ ] Yes

PARENT(S) / GUARDIAN INFORMATION:

Last Name ____________________________

First_________________________________

Address _____________________________________________________   

____________________________________________________________

Home Phone# ( ) ________________

Work Phone# ( ) ________________

Cellular# ( ) ____________________

Spouse’s Name______________________________________________

Address (if different from above) _________________________________

____________________________________________________________

Home Phone# ( ) ________________

Work Phone# ( ) ________________

Cellular# ( ) ____________________

IN AN EMERGENCY, IF PARENTS/GUARDIANS CANNOT BE CONTACTED:

Contact’s Name _______________________________________________

Phone # ( ) _____________________

Relation to Athlete _____________________________________________

Primary Care Physician _________________________________________

Doctor’s Phone# ( ) _________________________________

List Known Allergies________________________________________________________________

              ________________________________________________________________

              ________________________________________________________________

List any Medications presently being taken

              ________________________________________________________________

              ________________________________________________________________

              ________________________________________________________________