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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: _____________________

________________________________________________________

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