Mishicot High School Athlete Emergency Information Card SPORT(S) Check all that appl Fall: Football Cross Country Volleyball Dance Winter: GDance Basketball 0 Wrestling Spring: a Golf... Track. Softball a Baseball Athlete Name: _Birth Date: Tat oan Gender: Grade: Height: Weight Address’ City: State:__ Zip: Parent/Guardians Phone ‘Retaton) (Wael Phone 2 Phone 1 ‘elation (Same) Phone 2: Altemative Emergency Contacts Phone | ‘elation (Same) Phone 2;Current Medications: Known Allergies: Preferred Emergency Facility (If Possible): Family Physician: Phone: Dentist: Phone: Other Specialist: Phone: Insurance Information ‘Company Name: Group Number: Policy Number: Other Necessary Information: ito have your son ordaughs treated at a doctor's fice of hoyptal emergency room i th event hat he Tae athlete depatmsnt is secking your penis mene. Fan emergency occu very effort wl be made contac ou, [such cont sox posible his lor shes found in need of emeraency medial are may filtateprompe treatment Thereby give my permission for to receive emergency medical treatment, (aah Nay Parent/Guardian Signature: Date: