SVS Lacrosse Health Form



Name:___________________________________ Age:____________ US Lacrosse Number: ________________________


Allergy History (yes/no)

Hay Fever ________
Asthma _________ If yes, do you use an inhaler? ________
Eczema __________
Hives ____________
Insect Stings_________ If yes, do you have an Autoinjector/ EpiPen?________

Please list any allergy medication taken on a regular basis.



Drug Allergy (yes/no)

Sulfa _____________
Penicillin _________
Antibiotic __________ If yes, please provide the type _____________.
Other _____________________________________________________

Emergency Contact Information:

Emergency Contact Number One: ______________________________ Relation: ____________________

Emergency Contact Telephone Number: ______________________________________

Emergency Contact Number Two: ______________________________ Relation: ____________________

Emergency Contact Telephone Number: ______________________________________

Insurance Information:

Name of Insurance Company: ______________________
Name of Policy Holder: ___________________________
Policy Number: ________________________________


Emergency Authorization:
In the event I cannot be reached in an emergency, I hereby give permission to physicians selected by the coaches and staff of SVS Lacrosse to hospitalize, secure proper treatment for and to order injection and/or anesthesia and/or surgery for the person named above.

Parent Signature: __________________________