Dartmouth High School Athletic Department
AUTHORIZATION FOR MEDICAL TREATMENT and
EMERGENCY INFORMATION
I give my permission for the evaluation/treatment of ______________________________________________by any duly
Student’s Name – PLEASE PRINT
licensed physician and/or hospital facility in the event of illness or injury. I also authorize transportation in an
ambulance if necessary.
Parent/Guardian’s Signature_____________________________________________________ Date ________________
Address _____________________________________________ City ______________________
Date of Birth ____________________________
Zip Code: _____________
Telephone # __________________________________
Age__________
Sport ____________________________________ Class Year ______________
Parent/Guardian’s Name ______________________________________________________ Tel. # _____________________
Father_______________________________
Home#__________________________
Work/Cell #____________________
Mother______________________________
Home#__________________________
Work/Cell #____________________
Alternate Emergency Contact Person ________________________________________________________________
Relationship_____________________________ Telephone # (s) ____________________________/_________________________
Athlete’s Physician’s Name and Telephone #: __________________________________________________________________________
Please answer the following medical history questions:
Please check if the athlete has any of the following:
Concussions: Yes__________ No ___________
 Please provide information relative to any head injury history________________________________________________________
Diabetes ____________ Epilepsy ____________ Heart Condition __________
Asthma ___________
 Diabetic students must have glucose tablets and a glucometer present at all practices and games.
 Asthmatic students must have inhaler present at all practices and games.
 All athletes must report any medical changes to the Athletic Director and the Nurse.
Does the athlete wear contact lenses to participate?
Yes________
Other ___________
No _________
Please list ALL medications, including inhalers and directions for use:
Please list ALL allergies, including medications, food and insects:
Please list any other pertinent medical information:
Please provide all insurance information below:
____________________________________
Policy Name
_______________________
Policy Number
________________________________________
Subscriber’s Name
__________________________________________________________
Primary Care Physician (if applicable)
I give the medical staff at Dartmouth High School permission to share any medical information regarding my child’s
injury, illness, past medical history, allergies, or any other pertinent information necessary for my child’s care, to the
team physicians, or any other physician(s) involved in my child’s care, emergency medical technicians (EMT’s), school
nurses, my child’s coaches and any member of the school’s medical staff in order to facilitate care of my child.
________________________________________________________________________
______________________
Parent/Guardian’s Signature
_________________________________________________________________
Student’s Signature
Date
_____________________
Date
Revised November, 2011
Yellow form
ATTENTION PARENT/GUARDIAN
Please fill out the information below, sign wherever indicated, and return this sheet on or
before the first day of practice.
My son/daughter is a transfer student and played the following sports at their previous school.
___________________________
Fall Season
____________________________
Winter Season
__________________________
Spring Season
_________________________________________________________________________________________
Student’s Name – PLEASE PRINT
_________________________________________________________________________________________
I have read the information in the Dartmouth High School Athletic Handbook.
(STUDENT’S SIGNATURE)
I am aware of the school insurance plan which costs $8.00 for the school year and that it covers my child in all
Dartmouth High School functions and that it is a non-duplicating insurance. I (plan to) or (do not plan to) enroll in
school insurance under the Gerard Lefebvre Insurance Agency. (Please cross out one)
I am aware of the Training Rules at Dartmouth High School, the Massachusetts Interscholastic Athletic Association
Academic Requirements, and the practice and game schedules of the
_____________________________________________________________________________season.
TEAM/SPORT
In order for him/her to be a member of the __________________________________________ team, he/she must
abide by the rules stated in this Athletic Handbook.
________________________________________________________________________________________
Student’s Name (PLEASE PRINT)
_______________________________________________________________
________________
Signature of Parent/Guardian
Date
My daughter/son _______________________________________________ has my permission to participate in the
sport of _____________________________________________for the 2011-2012 school year at Dartmouth High
School. He/she also has my permission to be transported to away athletic events by Dartmouth School Department
official transportation.
In the event of a medical emergency, if I am not available, I hereby give permission to DHS coaches and staff to
secure proper treatment for my son/daughter
__________________________________________________________________________________________
Signature of Parent/Guardian
Revised November, 2011
Yellow form