This emergency information card collects important contact and medical details about an athlete in case of an emergency. It requests the athlete's name, age, address, phone number, social security number, sport, and emergency contacts including names, addresses, phone numbers, and relationship to the athlete. It also collects the athlete's insurance information, physician contact details, and medical details including any allergies, medical conditions like asthma or diabetes, current medications, contact lens use, and any other relevant health information. The card is to be signed and dated by the athlete's parent or guardian.
1. Emergency Information Card
Athlete’s name ________________________________________________________ Age ______
Address ____________________________________________________________________________
Phone ________________________________________________ S.S. #________________________
Sport ________________________________________
List two persons to contact in case of emergency:
Parent or guardian’s name ____________________________________________________________
Address ___________________________________________________________________________
Home phone _____________________________ Work phone _____________________________
Second person’s name _______________________________________________________________
Address ___________________________________________________________________________
Home phone _____________________________ Work phone _____________________________
Relationship to athlete ______________________________________________________________
Insurance co. ___________________________________ Policy # ___________________________
Physician’s name _____________________________________ Phone ______________________
IMPORTANT
Is your child allergic to any drugs? _______ If so, what? _________________________________
Does your child have any other allergies? (e.g., bee stings, dust) _________________________
Does your child suffer from _______ asthma, _______ diabetes, or _______ epilepsy?
Is your child on any medication? _______ If so, what? __________________________________
Does your child wear contacts? _______
Is there anything else we should know about your child’s health or physical condition? If yes,
please explain. _____________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
_______________________________________________________ _________________________
Signature Date