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HC Crittenden Intramural Medical Emergency Release Form Fall 2023
This form must be filled out by a legal guardian.
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* Indicates required question
Student Name (First and Last)
*
Your answer
Student Grade
*
Grade 7
Grade 8
Sport
*
Choose
Boys Soccer
Girls Soccer
I give permission for the Byram Hills District coach to take my son/daughter to a hospital emergency room for treatment if necessary during the designated practices/workouts.
*
Yes
No
Parent Name (First and Last)
*
Your answer
Parent Email Address
*
Your answer
Daily medication
*
Yes
No
If answered yes to the above, please explain:
Your answer
EpiPen?
*
Yes
No
Inhaler?
*
Yes
No
Known Allergies?
*
Yes
No
If answered yes to the above question, please explain:
Your answer
Phone number where you may be reached in case of an emergency:
*
Your answer
Alternate emergency contact name if you cannot be reached:
*
Your answer
Alternate emergency contact cell phone number if you cannot be reached:
*
Your answer
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