HOPKINTON MIDDLE/ HIGH SCHOOL
MEDICAL AUTHORIZATION FORM
Student’s Name: _____________________ Date: ____________
In the event that I cannot be reached and/or the team is out of the district during an interscholastic event, I hereby authorize and give permission to the designated Hopkinton Middle/ High School coach or other representative, if it is deemed necessary, to take my child to the nearest hospital room or emergency room or doctor’s office and to admit my child for treatment.
I further understand that all expenses and liability for said expenses incurred shall be fully assumed by me.
_______________________ _______________
Signature of parent/ guardian Phone Number:
_______________________ _______________
Insurance carrier: Policy Number:
Although completion of the information below is not mandatory, it is
strongly urged that you do so to alert coaches and/or medical
personnel of important information
1)Known medical allergies (ie. medication, food, insects, environment): _____________________________________________________
_____________________________________________________
2)Preexisting medical conditions (ie. asthma, seizures, depression etc.)
_____________________________________________________
_____________________________________________________
3)Commonly used medications or inhalers: _____________________
________________________________________________________
MEDICAL AUTHORIZATION FORM
Student’s Name: _____________________ Date: ____________
In the event that I cannot be reached and/or the team is out of the district during an interscholastic event, I hereby authorize and give permission to the designated Hopkinton Middle/ High School coach or other representative, if it is deemed necessary, to take my child to the nearest hospital room or emergency room or doctor’s office and to admit my child for treatment.
I further understand that all expenses and liability for said expenses incurred shall be fully assumed by me.
_______________________ _______________
Signature of parent/ guardian Phone Number:
_______________________ _______________
Insurance carrier: Policy Number:
Although completion of the information below is not mandatory, it is
strongly urged that you do so to alert coaches and/or medical
personnel of important information
1)Known medical allergies (ie. medication, food, insects, environment): _____________________________________________________
_____________________________________________________
2)Preexisting medical conditions (ie. asthma, seizures, depression etc.)
_____________________________________________________
_____________________________________________________
3)Commonly used medications or inhalers: _____________________
________________________________________________________
