XAVIER HIGH SCHOOL

30 WEST 16^th STREET, NEW YORK, N.Y. 10011-6302 – (212) 924-7900

ATHLETIC OFFICE

 EMERGENCY MEDICAL AUTHORIZATION

 Athlete's Name _______________________________________________

 Birth Date __________________                        Grade ______________

 Parent's Name _________________________________________________

 Home Phone (_____)____________________________________________

 Business Phone (_____)__________________________________________

 Address __________________________________________Zip _________

 In the event the parents cannot be contacted, please contact:

____________________________________Phone Number (____)__________

List sports the above named athlete plays:

1.____________________________

2.____________________________

3.____________________________

I hereby give my consent for medical treatment deemed necessary by physicians designated by school authorities and/or for transportation to a hospital emergency room for treatment for any illness or injury resulting from his athletic participation. I understand this authorization will only be enforced when I cannot personally be contacted and provide for immediate treatment.

 ________________________________            ______________________________

Parent's Social Security Number                        Student's Social Security Number

 _________________________________            ______________________________

Parent's Signature                                              Date