Athletics - Emergency Information Card

Student Information
Student Address
Student Contact Info
(not your Delta e-mail)
Parent Information
Emergency Contact Information
Contact #1
Contact #2
Student Health Info

Please provide other health information needed in case of an emergency. Include such conditions as:  serious allergies, asthma, diabetes, ear and eye problems, heart conditions, seizure disorders, orthopedic conditions:

Insurance Information

Permission is hereby authorize San Joaquin Delta College to obtain through a physician of its own choice any emergency medical care that may be necessary while he/she is participating or traveling under San Joaquin Delta College supervision. I also authorize the College Athletic trainer to administer those treatments deemed necessary by the team physician.  

 

Signatures
Please type your Full Name
(If student is under 18 years of age.)
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