ROYAL HIGH SCHOOL Athletic Department/ Athletic Training 34499 Royal Rd. • Brookshire, TX 77423 (281) 934-6657
Emergency Information Sheet Please note all information gathered is kept confidential and used for medical purposes only. Tenga en cuenta toda la información obtenida se mantiene confidencial y usada sólo con fines médicos. Name_____________________________
Sport(s) ______________________
Social Security #________________________
D.O.B___________
Grade_______
Home Address_____________________________________________________________________ Street City State Zip code Mother /Guardian____________________________ Home Phone___________________
Father/Guardian ________________________
In Case of Emergency Contact: Name__________________________ Telephone________________________
INSURANCE INFORMATION Do you have medical insurance? Yes____
No____
Name of Insurance Company______________________________________________________ Policy #_________________________________ Group #__________________________________ (If applicable) Policy Holder’s Name____________________________ SSN________________________ Policy Holder’s Address_____________________________________________________________ Policy Holder’s D.O.B______________________
*PLEASE MAKE A COPY OF THE FRONT AND BACK OF INSURANCE CARD AND INCLUDE WITH PACKET*
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