LAKE ZURICH HIGH SCHOOL
ATHLETIC EMERGENCY INFORMATION
(All information must be completed)
Sport Coach Grade
Athlete’s name ___________ D.O.B.
Address ________________________________________________
Home Phone ______SS# __________
Parent / Guardian’s name _______________________________
Place of Employment _______Work phone
Other phone #’s (car, cell, pager, etc.) ____________________
__________________________________________________________
Emergency contact--if parent / guardian cannot be reached
Phone: Home Work Other
Physician’s name ____________Phone
Insurance carrier Policy #
Routine medications (List:)
Medication allergies
Other allergies _____
Additional information (asthma, diabetes, epilepsy, heart condition, wear contacts, etc.)
Previous athletic injuries
If parent or guardian or any of the above listed people cannot be contacted in case of serious injury or illness, I authorize the school to take such emergency action as may be deemed necessary, including the transportation of the student to a hospital, medical center, or physician.
Signature of parent or guardian Date