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Emergency Information Card

Please complete the form below. Required fields marked with an asterisk *

Athlete's Name*

Answer Required

Grade (2022-23 School Year)*

Answer Required

Date of Birth*

Answer Required

Home Address*

Answer Required

City, State, Zip*

Answer Required

Father's Name/ Phone #*

Answer Required

Mother's Name/Phone #*

Answer Required

Emergency Contact (Other than parents)/Phone #*

Answer Required

Family Physician/Phone:*

Answer Required

Insurance Company/Policy#*

Answer Required

Allergies:*

Answer Required

Medical conditions:*

Answer Required

Hospital preference (if available)*

Answer Required

The Blackhawk Christian athletic department is seeking your permission to have your son or daughter treated at a doctor's office or hospital emergency room in the event that he or she is found in need of emergency medical treatment. If an emergency occurs every effort will be made to contact you. If such contact is not possible your permission may facilitate prompt medical treatment.

I hereby give my permisssion for (athlete's name) to receive emergency medical treatment.*

Answer Required

Parent/Guardian Signature / Date*

Answer Required