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Name_____________________________________ Date________ Sport_____________________
School Information: Home Information:
Address ___________________________ Address _______________________________________
City, Zip ___________________________ City, Zip ______________________________________
Phone # ___________________________ Phone # _______________________________________
Person to contact in case of emergency_____________________________ Phone #______________ Relationship________________
Insurance Information:
Name of insurance company___________________________________________________________________
Address of insurance company_________________________________________________________________
City, state, zip _____________________________________________________________________________
Insurance company phone #___________________________________________________________________
Insurance policy number______________________________________________________________________
Name of insured___________________________________________________________________________________
Emergency Information:
Drug allergies ___________________________________________________
Current medications_______________________________________________
Do you have a history of head injuries or seizures? Yes No
If yes, please explain___________________________________________________________________________________
Are you allergic to bee or wasp stings? Yes No
If yes, please explain___________________________________________________________________________________
Do you have any other medical conditions that emergency medical personnel should be aware of?
If yes, please explain___________________________________________________________________________________
Do you have any family history of unexplained or cardiac caused sudden death under age 50?
If yes, please explain___________________________________________________________________________________
Have you ever had any type of surgery?__________________________________________________________________________________
Do you wear glasses or contact lenses when you play? Yes No
If yes, which do you wear?____________________________________________________________________________________
I hereby give permission to be treated by the Columbus State team physicians and/or their consulting physicians and athletic trainers for any or all medical treatment or emergencies while a member of a Columbus State athletic team to include practices, games, and travel. When necessary, I grant permission for treatment by emergency medical personnel and hospitalization at an accredited hospital.
I certify that no information regarding my medical history has willfully been omitted, and that to the best of my knowledge, recollection, and belief, the information I have given on this record is an accurate and complete account of my medical history.
Athlete Signature__________________________________________________________________________
Special medical alert_______________________________________________________________________