Yorktown High School Crew School Year 2017-2018
Emergency Information and Treatment Release
ROWER INFORMATION
Student Last Name:First Name:
Date of Birth:
Grade:
Home Address:
Home Phone Number:
Student Cell Number:
Student Email:
PARENT/GUARDIAN INFORMATION
Parent/Guardian 1 Name:
Address (if different):
Email:
Home Phone Number:
Cell Phone Number:
Work Phone Number:
Parent/Guardian 2 Name:
Address (if different):
Email:
Home Phone Number:
Cell Phone Number:
Work Phone Number:
EMERGENCY CONTACTS
(Friend or Relative to be called when neither parent can be reached – List two contacts)
Emergency Contact 1 Name:
Relationship to Student:
Phone Number:
Alternate Phone Number:
Emergency Contact 1 Name:
Relationship to Student:
Phone Number:
Alternate Phone Number:
ATTACH A COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARD FOR YOUR CHILD TO THIS FORM
MEDICAL INFORMATION
Physician’s Name:
Physician’s Phone:
Name of Insurance Provider:
Policy Number:
Group Number:
Does your child use an Inhaler? ______Yes ______No
Has your child been prescribed an Epipen? ______Yes ______No
Does your child use Contact Lenses?______Yes ______No
Does your child have allergies?______Yes ______No
Is your child allergic to any medications?______Yes ______No
Does your child have prior injuries?______Yes ______No
If you answered yes to any of the questions above, please provide additional details in the space below.
List any medications that your child is currently taking:
What is the date of your child’s last tetanus shot:
TREATMENT RELEASE
Yorktown High School (YHS) coaches and trip chaperones have my permission during YHS Crew related activities to administer emergency medical care and/or take my child to the emergency room of the nearest hospital or other emergency medical facility in a private automobile, bus or emergency vehicle in the case of an emergency. I will not hold YHS Crew, their coaches or trip chaperones liable for any action taken in administering emergency medical care or providing transport for my child in relation to a YHS Crew related activity.
In connection with YHS Crew related activities, I further authorize medically-trained personnel to provide treatment deemed necessary for the well-being of my child.
Signature or Parent/Legal Guardian ______Date ______
ATTACH A COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARD FOR YOUR CHILD TO THIS FORM