FAITH BAPTIST SCHOOL		ATHLETICS TEAM EMERGENCY INFORMATION	ALLERGIC TO: ______________________________
Salisbury, MD 21804			School Year:  ___________			___________________________________
410-742-9516									HEARING IMPAIRED ______  HEARING AID _______
									VISUALLY IMPAIRED _____  GLASSES or CONTACTS _______
									DAILY MEDICATIONS: _______________________________
 									OTHER:  __________________________________________
	
CHILD'S NAME:  _____________________________________________________________   	DATE OF BIRTH: _________________
                               (Last)                                   (First)                         (Middle)                                                  (Mo/Day/Year)

ADDRESS:  _______________________________________________________________________________________________________
			(Street)                                                                            (City)                           (State)         (Zip Code)

FATHER'S NAME:  _____________________________		MOTHER'S NAME:  __________________________________

EMPLOYER:  _________________________________		EMPLOYER:  _______________________________________

WORK/CELL PHONE #:  ________________________		WORK/CELL PHONE #:  _____________________________

NAME OF PERSON AUTHORIZED TO PICK CHILD UP FROM SCHOOL DAILY:  ____________________________PHONE#_________________

When parents cannot be reached, list one person who may be contacted in an emergency.

NAME:  _________________________________________	RELATIONSHIP:  ___________________ PHONE #:  ____________________

CHILD'S PHYSICIAN:  _________________________________	CHILD'S DENTIST:  ________________________________________

ADDRESS:  _________________________________________	ADDRESS:  _______________________________________________

PHONE NUMBER:  ____________________________________	PHONE NUMBER:  _________________________________________

In the event of an emergency requiring immediate medical attention, my child may be taken to the NEAREST EMERGENCY ROOM.   My signature authorizes the school to have my child transported to the emergency room and for the necessary emergency treatment to be given.

____________________________________________	____________		__________________________________________
                   Parent's signature                                                 Date				Home Phone Number
SPORT:  ________________________	Fee:  ______________		Date Paid:  _________		Check #__________