HERITAGE MIDDLE SCHOOL ATHLETICS MEDICAL INFORMATION CARD
*Fill out this page in blue or black ink only*
Name_______________________________ DOB______________________________ Age______________
Address______________________________________ City_________________ State__________ Zip Code________
Sport(s) in which you will be trying out for at Heritage Middle School
Abbreviated medical history (previous injuries, medical problems, etc.)
_______________________________________________________________________________________________________
List any allergies you have
List any medications you currently take
Name of Father (or guardian) Email address
Cell phone # Work phone #
Name of Mother (or guardian) Email address
Cell phone # Work phone #
In case of emergency, contact (other than parent or guardian)
1. Name Relationship Phone #
2. Name Relationship Phone #
Primary Care Physician
Name Phone #
Insurance Provider: _________________________
Group Number __________________________
Policy Number _____________________________
In case of an emergency or accident on school grounds or during any school activity involving my
child__________________________, which in the opinion of the school authorities present, requires
immediate attention or surgical attention, I hereby grant permission to said school authorities to obtain
services of a physician or to transport said child to the hospital or emergency facility if it is deemed necessary
by school authorities. I hereby grant permission also to said physician to read said condition unless I am
present and request otherwise or until I later request otherwise.
__________________________________ ___________________________
Parent or Guardian Signature Date
