RHS Permisison To Treat

Radnor Township School District Permission from Parent, Guardian for Medical Treatment
School Year*
Sport*
Athlete Last Name*
Athlete First Name*
Grade*
School District*
Athlete Date of Birth*

MonthDayYear
Date
As a parent/guardian I expect every effort will be made to contact me in order to receive my specific authorization before any treatment or hospitalization is undertaken.
Athlete Home Phone*
Format: (000) 000-0000.
Athlete Cell Number
Father's/Guardian's Name
Father's/Guardian's Cell Number
Mother's/Guardian's Name
Mother's/Guardian's Cell Number
Athlete Home Address*

Street Address

Street Address Line 2

CityState

Zip
If Parent cannot be reached call:
Emergency Contact Name #1
Cell Number
Relationship
Emergency Contact Name #2
Cell Number
Relationship
Print Parent/Guardian Name
In the event of an emergency requiring medical attention, I grant permissison to a physician or other hospital personnel designated by the Radnor coaching staff to attend my son/daughter.
Signature Parent/Guardian*
Date*

MonthDayYear
Date
Family Physician*
Physician Phone Number*
Dentist
Dentist Phone Number
You are required to provide medical insurance coverage in order to participate in our interscholastic program. This certifies that my child has proper and adequate coverage.
Medical Insurance Company*
Policy No.*
Group No.
Subscriber SS #
Subscriber Name*
Does your child wear: contacts/ glasses Has you child ever had: asthma/ diabetes / kidney injury / heart condition If yes, please explain:
If yes, please explain
Is your child allergic to any medication?*
Is there any condition other than stated above, that a physician should be aware of?
7th8th9th10th11th12thNot Applicable
Should be Empty: