High School Athlete Medical Information Form
Personal Information
Athlete Name
Date of Birth
Grade
Sport
Home Address
Parent/Guardian Name
Parent/Guardian Phone
Parent/Guardian Email
Emergency Contact
Name
Relationship
Phone 1
Phone 2
Medical Information
Primary Physician Name
Physician Phone
Medical Insurance Provider
Policy Number
Known Allergies
Current Medications
Relevant Medical Conditions or Past Injuries
Activity Restrictions
Permissions
Consent for Emergency Medical Treatment
Yes
No