Player Emergency Information Sheet

Player’s Name: ___________________________________ Date of Birth: _______________________

Address: ___________________________________________________________________________

Health Insurance #: ____________________________________

Parent’s/Guardian’s Name: ____________________________________________________________

Telephone: _____________    Cell Phone: _____________    Business Phone: _____________ 

1st Emergency Contact Name: ___________________      Relationship: ___________________  

2nd Emergency Contact Name: ___________________      Relationship: ___________________ 

Family Doctor: _________________________________ Telephone #:__________________________


Are you allergic to any drugs? (if so, please list) Yes _____ No _____

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Do you have any allergies (i.e. bee stings, dust, etc)? Yes _____ No _____

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Do you suffer from a serious illness (i.e. Asthma, Epilepsy, etc)? Yes ____ No ____

___________________________________________________________________________________


Are you on regular medication? Yes _____ No _____

____________________________________________________________________________________


Do you wear contact lenses? Yes _____ No _____


Any other comments or relevant Information: 
____________________________________________________________________________________

____________________________________________________________________________________

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Signature Parent/Guardian					Date