Harnett County Schools Emergency Information - Consent to Treat General Information Students Full name: _____________________________________________ Date of Birth: _______________ Parent/Guardian Name:_____________________________________________________________________ Address: _________________________________________________________________________________ _________________________________________________________________________________ * Please place a check mark next to the primary emergency contact* ___ Father’s Home Phone # ( ___ ) _____-__________ Work # ( ___ ) _____-__________ Cell# ( ___ ) _____-__________ ___ Mother’s Home Phone # ( ___ ) _____-__________ Work # ( ___ ) _____-__________ Cell# ( ___ ) _____-__________ ___ Other Emergency Contact Name _________________________________ Relationship _______________ Primary Phone # ( ___ ) _____-__________ Important Student Medical Information Allergies (medication or other) : _________________________________________________________________________ Medications: ________________________________________________________________________________________ Past Medical Problems: ________________________________________________________________________________ ___________________________________________________________________________________________________ Insurance Information Insurance Company Name: ____________________________________________________________________________ Address: ________________________________________ City: ________________ State: ______ Zip Code:__________ Group #:__________________________________________ Policy #: ________________________________________ Is this insurance company: ____ HMO ____ PPO ____ Other: _____________________________________________ Does your insurance require a referral form from a primary care physician?

____ Yes

____ No

Parental Permission As the parent/legal guardian, I give consent for the above named student-athlete to receive a medical screening prior to participation in athletics. If the student-athlete is injured while participating in athletics and the school is unable to contact the parent/legal guardian, I grant permission for treatment deemed necessary for a condition arising during participation in these activities. Treatment may include, but is not limited to, first aid, CPR, the use of AED, or medical/surgical intervention as recommended by a physician. As parent/guardian, I accept the financial responsibility for any such medical care and treatment. Either a licensed athletic trainer or a trained first responder is available for high school student athletes. Licensed athletic trainers, within their scope of practice and protocol, provide care, prevention and rehabilitation of injuries incurred by student athletes and who, in carrying out these functions, may use physical modalities including heat, light, cold, electricity, or mechanical devices related to rehabilitation and treatment , injury treatment may include the application of modalities such as heat, cold, electrical muscle stimulation as well as therapeutic exercises to safely speed recovery and return to activity. First responders may use the application of heat and ice and render first aid within their scope of training and practice. I give my permission for the release and exchange of health related information with my child’s physician and the athletic team members necessary to appropriately care for my child. We hereby state that, to the best of our knowledge, the above information is correct and we will hereby notify the school if changes occur. Parent/Guardian Signature: ____________________________________________________ Date: ____________________