2012-2013 Brandeis University Sports Medicine Department
Contact, Insurance and Personal Information Form

CONTACT INFORMATION

FULL NAME
SPORT(S)
DATE OF BIRTH (MM/DD/YYYY) 
HOME ADDRESS
HOME TOWN  STATE  ZIP 
HOME PHONE #  CELL PHONE #
SCHOOL ADDRESS (Off Campus or Dorm)
EMAIL ADDRESS
PARENT OR GUARDIAN NAMES
PARENT OR GUARDIAN PHONE #

EMERGENCY CONTACT INFORMATION

Someone we can contact if you are injured and your parent or guardian cannot be reached. Cannot be a teammate or Coach at Brandeis University.
NAME  CELL PHONE #
ADDRESS
RELATIONSHIP TO YOU (i.e. aunt, friend, neighbor)

INSURANCE INFORMATION

COMPANY NAME
POLICY HOLDER
INSURANCE ID NUMBER

**PLEASE BRING YOUR INSURANCE CARD WITH YOU TO CAMPUS SO THAT WE MAY KEEP A COPY FOR OUR RECORDS **

PERSONAL INFORMATION

MEDICATIONS (anything you are currently taking)



ILLNESS



ALLERGIES


INJURIES (those that will require treatment, past or present)

NAME 

LAST FOUR DIGITS OF SAGE STUDENT ID #

DATE (MM/DD/YYYY) 

BY CHECKING THE FOLLOWING BOX, I ACKNOWLEDGE THAT ALL THE ABOVE INFORMATION IS ACCURATE AND TRUE