HEALTH AND INJURY INFORMATION CARD and CONSENT FOR MEDICAL TREATMENT FORM
(This form is to be completed and kept available for reference wherever competition takes place. Update medical information as necessary.)
Student's Full Name
First Name
Last Name
Age
Grade
Date of Birth
Student's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Information
1st Parent/Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
1st Parent/Guardian Place of Work
2nd Parent/Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
2nd Parent/Guardian Place of Work
Emergency Contact when parent/guardian cannot be notified:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Information
Family Physician
First Name
Last Name
Physician Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Hospital
Family Dentist
Date of last tetanus booster:
-
Month
-
Day
Year
Date
Do you wear:
Glasses
Contacts
Dentures
List ant known allergies, drug reactions, or other pertinent medical information. (Diabetes, seizures, history of headinjury with unconsciousness or concussion, medications, etc.)
Please note and date any new injury information here:
CONSENT FOR MEDICAL TREATMENT
Iowa law requires a parent’s, or legal guardian’s, written consent before their son or daughter can receive emergency treatment, unless, in the opinion of a physician, the treatment is necessary to prevent death or serious injury. As the parent(s), or legal guardian(s), of the child named above, I (we) authorize emergency medical treatment or hospitalization that is necessary in the event of an accident or illness of my (our) child. I (we) understand that this written consent is given in advance of any specific diagnosis or hospital care. This written authorization is granted only after a reasonable effort has been made to contact me (us).
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
Should be Empty: