Step 4: Fill Out the Emergency Card Form

Medical Authorization and History


Bourne High School Athletics 75 Waterhouse Road, Bourne, MA 02532 508-759-0674 Emergency Medical Authorization

Athlete’s Name:	*

Year of Graduation:	*

Mail Address:	*

Village:	*

Zip code:	*

Date of Birth:	*

Mother/Guardian:	*

Employer:	*

Home phone:	*

Work phone:	*

Cell phone:	*

Father/Guardian:	*

Employer:	*

Home phone:	*

Work phone:	*

Cell phone:	*



Emergency Contacts (in addition to names above):

Additional Emergency Contact 1:

Name:

Relationship:

Phone:

Additional Emergency Contact 2:

Name:

Relationship:

Phone:



IN CASE OF AN EMERGENCY, we will attempt to contact the parent/guardian before calling emergency medical services. Your child may be transported by ambulance to an emergency care facility. Please list the hospital of your choice (we will try our best to honor that choice).

Hospital:	*

Phone Number:	*

Family Doctor:	*

Phone Number:

Family Dentist:	*

Phone Number:	*

	* Do you have health Insurance for your child?
		Yes
		No

Health Insurance Company:	*

Policy #:	*

Dental Insurance Company:	*

Policy #:	*

I give my permission to the Bourne Public Schools Athletic Department to share information relevant to my child’s health condition with appropriate school personnel when needed to meet my child’s health and safety needs. I also give my permission to exchange information with my child’s physician for the purpose of referral, diagnosis and treatment.

Parent/Guardian’s Full name:	*

Date:	*



Bourne High School Athletics 75 Waterhouse Road, Bourne, MA 02532 508-759-0674 Medical History Questionnaire

Athlete’s Name:	*

Medical History

	Please check all that apply:
		Asthma	Diabetes
		Migraines	Seizures
		Epilepsy	Heart Conditions
		High Blood Pressure	Eating Disorders

Other medical conditions:

Do you have any allergies to foods/medications, etc. (please specify):

Do you take any medications (please specify):

	Do you wear contact lenses or glasses during your athletic participation?
		Yes
		No

	If you wear glasses, are the lenses shatterproof?
		Yes
		No

	OR Will you wear protective goggles over your glasses?
		Yes
		No

	Are you currently being treated for any health conditions not listed above?
		Yes
		No

Please explain:

Do you have any chronic or recurrent type of injury that needs protection or support? Please list here:

Do you have a disease that affects the function of any eye, ear, testicle, kidney or lung? Please explain:

Do you have a family history of heart disease? Sudden death?

Additional Information:



The above responses are true and correct to the best of my knowledge.

Parent/Guardian’s Full name:	*

Athlete’s Full name:	*

Date:	*

Sport:

Send a copy of the completed form to this email address :

* Indicates Required fields.