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ATHLETIC EMERGENCY CARD - BUCHANAN HIGH SCHOOL Please Print
Student Name _____________________________________ Sport 	SID#
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Address _____________________________ City ____________ Zip ________ Phone ____________ Cell	
Insurance Co. ___________________________________Policy No. _________________Group No.
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Insurance Co. Address _________________________________________________ Phone 	
DOB_______________ Date of Last Tetanus booster _____________________	Contact Lens? Yes or No
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Are you allergic to any medications? Please list	
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Any other allergies? Please list Presently taking any medication(s)? Asthma? Yes or No	Inhaler? Type

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Person to contact in case of emergency:
1. ___________________________________Phone Hm. ________________ Wk. ____________ Cell 2. ___________________________________Phone Hm. ________________ Wk. ____________ Cell
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3. ___________________________________Phone Hm. ________________ Wk. ____________ Cell 	T My son/daughter has permission to participate in athletics at Buchanan High School and to travel with his/her team(s) for athletic contests. Should it be necessary for my child to have medical treatment while participating in sports, or on a trip, and if the District is unable to contact me, I hereby authorize Clovis Unified School District personnel to use their judgment in obtaining medical services for my child. I understand that my child must have medical insurance that provides at least $1500.00 accidental injury coverage.                                                                                                  N
Parent/Guardian: 	 Date: