EMERGENCY CARD INFORMATION
THIS FORM IS TO BE KEPT ONN FILE BY THE CLUB AND IS EXPECTED TO PRESENT AT EVERY CLUB RELATED ACTIVIT*.
CLAREMONT COLLEGES CLUB SPORTS EMERGENCY CARD SPORT____________________
NAME___________________________________________ B.DATE_________________ AGE_____________
LAST FIRST
COLLEGE ADDRESS
DORM:___________________________ ROOM# ________________SCHOOL BOX# _______CELL________________ PHONE_________________
CAMPUS EXTENSION:_____________
OFF CAMPUS ADDRESS: # & STREET:______________________________________APT.____CITY______________________
COLLEGE_______________EMAIL ADDRESS_______________________________________SOC.SEC____________________
IN CASE OF EMERGENCY NOTIFY:____________________________________________________________
NAME & RELATIONSHIP
ADDRESS STREET CITY STATE ZIP
HOME PHONE ( ) ___________________ WORK PHONE: ( )____________________
KNOWN ALLERGIES_________________________________________________________________________________________________
MEDICAL INSURANCE CO._______________________________ POLICY NO.___________________________________
INURANCE CO. PHONE # ( ) _____________________ GROUP # OR MEMBER #_______________________
SIGNATURE________________________________________________________________________________DATE:____________
The athletic trainer and coach may apply first aid treaetment until the family doctor can be contacted.
Yes_____________________ No____________________
I give consent for the coaches and/or trainers to use their own judgement in securing emergency medical care and ambulance service.
Yes_____________________ No____________________
