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