Swartz Creek Athletic Department
Emergency Release Form

Athletes Name:   Age:    Grade:

Parents Name:   Sport: 

Address:   

Home Phone:    Work Phone: 

Emergency Contact Person:    Phone: 

Family Physician:    Phone:

Hospital Affiliation or Personal Preference: 

Health Insurance Provider:  Policy Number: 

List illnesses or injuries requiring medical attention in the past 12 months: 

List medications currently taken:   

List current allergies (food, insect, medication):

Permission for Treatment

In the event I cannot be reached, I grant permission to the Swartz Creek School System to provide emergency treatment for (son/daughter) and follow-up care by a physician or health care provider.

Parent/Guardian:

Signature:_____________________________________________ Date: