Emergency Form For Athletics: Do Not Send To The Nurse

Authorization For Treatment For A Minor:

Please fill in this athletic form and return it to the Benet Academy coach your son or daughter is working with. In the event of an emergency a person from Benet Academy other than a parent will bring it to the hospital with the student so that appropriate medical treatment can be administered.

Student's name: ____________________________________

Address: __________________________________________

Home Phone Number: _______________________________

Date of Birth: ______________________________________

Student's Physician: _________________________________

Last Tetanus Booster: _______________________________

Allergies, Problems, Medication(s): ____________________

___________________________________________________

Health Insurance Carrier: ___________________________

___________________________________________________

Policy Number: _____________________________________

In The Event I Cannot Be Reached----

I authorize emergency medical treatment for my child. I understand that this permission is given in advance of any specific situation and is done so to encourage medical personnel to use their best judgment in treating my child.

Signature: _________________________________________

Date: _____________________________________________

Witness: ___________________________________________

Date: _____________________________________________

Mother's Name: ____________________________________

Work Phone Number: _______________________________

Father's Name: _____________________________________

Work Phone Number: __________________________

If I am unavailable in the event of an injury then please contact:

Name : ____________________________________________

Phone Number: ____________________________________

Relationship:_______________________________________

It is imperative that your son or daughter fills out an accident report with the coach as soon as possible after the accident. The insurance carrier for Benet Academy will not process claims 30 days from the date of the accident. Many times a student will not inform the coach of his or her injury, thinking that the injury was not serious enough to warrant a report. We suggest that a report be filed no matter how serious the injury seems to be, just to be on the safe side.