Duchesne High School | Athlete Emergency Form

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Athlete Emergency Form

Student Name
DOB
Current Sport
Grade

Street

Apt, floor, suite, etc.

City
State
Zip

Phone
E-mail

Mother/Guardian Name
Mother Work #
Mother Cell #

Father/Guardian Name
Father Work #
Father Cell #

If parents cannot be reached, please list an additional person to contact in case of emergency.

Name
Relationship to Student

Home #
Work #
Cell #

Allergies
Long-Term Medication

Significant Medical History

PARENT SIGNATURE DATE

Current month ye@r (4 digits) day *