Medical, Insurance, and Emergency Contact Information for Athletic Teams

Copy goes with Group Leader on trip along
with Copy of Front Back of Insurance card
and short-term travel if International trip
Medical, Insurance, and Emergency Contact Information for Athletic Teams
All fields are required unless indicated. Legal First and Last Names must be used for all fields requiring a person - no nicknames
Student Athlete's Legal First and Last Name

First NameLast Name
Student's ID# (Required for ALL Ruth Murdock & AA Students) Use 000000 for Others
Student's Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student's Local Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student's Phone Number (If they have one, otherwise Parent's Phone #)
Format: (000) 000-0000.
Home Phone Number (if different)
Format: (000) 000-0000.
Name of Parent / Guardian

First NameLast Name
Parent's or Guardian's Phone Number
Format: (000) 000-0000.
Emergency Contact (Next of Kin): Legal first and last name
Emergency Contact: Relationship
Emergency Contact: Phone Number
Alternate Emergency Contact: Legal first and last name
Alternate Emergency Contact: Relationship
Alternate Emergency: Phone number
Do you take medications? If yes, list them below

Do you have allergies
Do you carry an Epi-Pen
If yes, list allergies
Blood type and Rh factor (optional)
Name and Phone Number of Doctor (optional)
Do you have any physical limitations that would interfere with the challenges of travel or study in the areas planned for this trip?
If yes, please describe what they are and how you need to be accommodated. The Travel Group Leader will try to accommodate your needs.
All participants are required to have US Health Insurance to travel - Medicaid is not acceptable outside of Michigan
Home address when not on the team (if different than local address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty: