8th Gr. Sports Med/Emerg. Form


(Last) (First) 

Date of Birth______/______/______ 

Address: ___________________________________
City________________  Zip____________

Parent (Guardian)__________________
Home Phone______________________ 
Work Phone_______________________ 
Cell/Pager ________________________ 
Parent (Guardian)__________________
Home Phone______________________
Cell/Pager _______________________
Work Phone ______________________

Persons to be called if above cannot be reached:

1. Name ______________________
Home Phone______________________ 
Work Phone ______________________  
2. Name _______________________ 
Home Phone _______________________ 
Work Phone _______________________ 
Cell/Pager _______________________

Student's Physician _____________________
Phone __________________________ 
Hospital ___________________________ 
Exchange _________________________ 
Student's Dentist ______________________ 
Phone ________________________ Exchange __________
 Is your child on any medication? ________No ________
Yes If Yes, please specify:
PARENT!S PERMISSION AND AUTHORIZATION FOR MEDICAL TREATMENT (Parent- Please initial to the left as an acknowledgment of your agreement)
______ In the event that my child needs emergency medical treatment and the parent or emergency contact cannot be reached, I give consent for Ladue Middle School to obtain through a licensed medical professional and hospital, such medical care that is reasonably necessary for the welfare of my child.
______ Permission is hereby granted to that attending physician to proceed with any medical or minor surgical treatment, x-ray exam land immunizations for the above- named student. In the event of an emergency arising out of serious illness, the need for surgery, or significant accidental injury, I understand that an attempt will be made by the attending physician to contact me in the most expeditious way possible. If said attending physician is not able to communicate with me, the treatment necessary for the best interest of the above-named student may be given.
_______ Permission is granted to the athletic trainer to provide the needed emergency treatment to my child prior to his/her admission to the medical facilities if necessary.


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