LNS MEDICAL EMERGENCY AUTHORIZATION FORM 2024/2025 SY

Please read and fill out this form completely, this information will be sent to the Lummi Nation School Office

I/we have read and understand the co-curricular rules, Concussion Information Sheet, and the Sudden Cardiac Arrest sheet located in the athletic packet of Lummi Nation School. I recognize the risk of injury in any activity of Lummi Nation School and agree to the rules set forth. This agreement shall be effective for the 2024/2025 school year.
Student Athlete Name "Printed"*
Student Athlete Signature*

Clear
Date*

MonthDayYear
Date
Parent/Legal Guardian Name "Printed"*
Parent/Legal Guardian Signature*

Clear
Date*

MonthDayYear
Date
Name of Student Athlete*
As the parent or Legal Guardian, I authorize the team physician or, in his/her absence, a qualified physician to examine the above-named student and in the event of injury to administer emergency care and to arrange for any consultation by a specialist, including a surgeon, he/she deems necessary to insure proper care of the injury. Every Effort will be made to contact the parent or guardian to explain the nature of the problem prior to any involved treatment.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Parents Home Phone*
Business Phones*
Please enter a valid phone number.
Emergency Contact Person
Name*
Phone Number*
Relationship of Contact Person*
Family Physician's Name*
Phone*
Name of Family Insurance Company*
Policy #*
Should be Empty:

Emergency Contact Person