INSURANCE INFORMATION
Parent Please Fill Out

For the school year of 2006-07, all LCS secondary student-athletes who compete on an LCS athletic team and are listed on the school's eligibility form (the VHSL Master Eligibility Form for the high schools) are covered by a blanket policy which LCS has purchased. This policy is the Basic Plan through Market Insurance, carried by the First Service Insurance Company. The policy number is 06545077. However, we also need to know if you have any other type of medical insurance coverage on your son or daughter. Please complete the information below as it applies to health insurance coverage for your student-athlete.

Please check the appropriate box. If you checked box number 2, then complete all requested information.

D 1. Other than the blanket policy which LCS is providing, my son/daughter is not covered by any other form of health insurance. D 2. Private Insurance
                Name of Company ___________________________________
                Policy number ______________________________________
                Phone number of Insurance Co.      ______________________
            (The phone number of insurance company must be supplied so that health provider can verify insurance coverage.)

EMERGENCY AND MEDICAL INFORMATION

Student's Name

 

 

 

Grade          

 

 Parent/Guardian

 

Address

 

Phone (H)

 

(W-Mother)

 

(W-Father)

 

(Other)

 

Two persons we can call in the event you cannot be reached: 

1.

 

 

 

Phone

                                                 2. ________________________________________________________

Major Illness? _________________________                                           Medication?______________________

Allergies? _____________________________                                          Previous head or neck injury? ________

Prior head-related problems?______________                                          Wears contact lenses while playing? ___

Braces or retainers?    ___________________                                           Last Tetanus shot?_________________

Are pupils unequal in size?________________                   If unequal, which is larger?__________________

Preference of Physicians: 1.________________________________ Phone __________________________
                                        2.________________________________  Phone __________________________

If neither physician is available, do we have your permission to take your child to a hospital or available physician? I hereby give my permission to the team physician(s) to provide medical services to my child.

Parent/Guardian Signature____________________________________
                                                                            (Required)
 

ATHLETIC TRAINER (School Use Only)

Date of valid physical: ___________________________      Comments:__________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________

TIME LOSS INJURY RECORD
DATE                     DIAGNOSIS                                                                                                                     TIME LOSS
___________    ________________________________________________    _____________________
___________    ________________________________________________    _____________________
___________    ________________________________________________    _____________________