UNION COUNTY HIGH SCHOOL

EMERGENCY MEDICAL AUTHORIZATION

The following information is very important in order to assure your student-athlete of prompt medical care in case of injury.

Please provide complete and legible information.

______________________________                        _______________________________________

STUDENT NAME                                                       ADDRESS

______________________________                        __________________________________               

DATE OF BIRTH                                                        MALE/FEMALE

______________________________                        _______________________________________

TELEPHONE                                                              SCHOOL ATTENDED LAST YEAR / CURRENT GRADE

______________________________                        _____________________________________________

PARENT(S)/GUARDIAN(S) NAME                           ADDRESS IF DIFFERENT FROM ABOVE

_________________________________                  _____________________________________________

WORK PHONE #’S                                                     CELL PHONE #’S

If parents divorced or separated, who is the custodial parent;_____Mother______Father______Joint

In case of emergency and parent is not available, please contact:

Name_______________________________ Phone #____________________________

Family Physician____________________________________ Phone #__________________________

Family Dentist______________________________________ Phone#___________________________

I/we authorize responsible school personnel to oversee or provide emergency medical care to participant in the event of serious injury.  This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained BEFORE the surgery IS PERFORMED

Ø      Medical Insurance Company_______________________________________

Ø      Policy #______________________________________

School representatives may administer the following ANALGESIC

Acetaminophen (Tylenol or generic)_______YES_________NO

Ibuprofen (Advil, Nuprin, Motrin, or generic)__________YES_______NO

Does your child use an inhaler?_______Yes_______No

Is athlete allergic to any medications?_____Yes_____No (If yes please specify)_______________________

Medication presently being taken__________________________________________________________

How often_______________________________ Dosage______________________________________

·          I/we authorize responsible school personnel to oversee or provide emergency medical care to participant in the event of serious injury.

·          I/we authorize the athletic department to publicize the achievements of the participant, including the participant’s name and likeness to media sources and on the school /athletic department website (Note: The Athletic Director must be contacted directly and in writing to rescind this authorization)

·          I/we authorize Union County High School to investigate and obtain information from police agencies, the probation department, or any other source regarding the events leading up to any arrest or filing of charges from an act which would be in violation of any of the rules and regulations as stated in the Athletic Handbook.

·          Parent/Guardian and Student acknowledgement and release (must be signed by student and Parent/Guardian):  I have read the rules and regulations of the Indiana High School Athletic Association and Union County High School and know of no reason why I am not eligible to represent my school in athletic competition.  If accepted as a representative, I agree to follow said rules and regulations of my school and the IHSAA and abide by their decisions.  I know that athletic participation is a privilege.  I know of the risks involved in athletic participation, understand that serious injury, and even death, is possible in such participation, and choose to accept such risk.  I voluntarily accept any and all responsibility for my own safety and welfare while participating in athletics, with full understanding of the risk involved.

·          Permission to ride to and from a sporting event with a coach or parent if school transportation is not available.

_________Yes, I give permission    _________No, I do not give permission

Parent/Guardian Signature______________________________________________   Date______________

Student Signature_____________________________________________________  Date______________