Emergency Card

SCHOOL YEAR ______                      JOHN MUIR MIDDLE SCHOOL                           GRADE _____

ACTIVITIES/ATHLETIC EMERGENCY INFORMATION CARD

                                                                                                                                    MALE ___  FEMALE ___

As a parent or guardian of ____________________________________________________________________

                                           (last name)                                         (first name)                         (middle initial)

In case of an emergency occasioned by an accident or injury, I give my permission to have the respective coach/supervisor consent to needed medical attention by the nearest physician and/or hospital.

 

Known allergies to drugs and anesthetics ________________________________________________________

Date of birth _______________________     Home Phone _______________     Cell Phone _______________

Father’s full name ____________________________    Address _____________________________________

Father’s employment ___________________________________________     Work Phone ________________

Mother’s full name __________________________     Address ______________________________________

Mother’s employment ___________________________________________    Work Phone ________________

Insurance Company & Number ________________________________________________________________

Family Doctor _________________________________________________     Telephone _________________

Family Dentist _________________________________________________     Telephone _________________

Emergency Contact ____________________   Relationship ________________   Telephone _______________

 

PARENT OR GUARDIAN SIGNATURE _____________________________________     Date ___________