Only COMPLETELY FILLED IN forms will be accepted. Doublehanded skippers and crews must EACH complete and sign separate copies of this form.
Name of Participant (printed): _____________________________________________________________
Name of Parent or Guardian (printed): _______________________________________________________
In the event of accident or injury to myself, my spouse or any child of mine (specifically including my child named below as the "Participant") or in the event of illness of myself, my spouse or any child of mine while in, on or about the premises of Granite Pier or while participating in any activity sponsored by or under the auspices of the Sandy Bay Sailing Program under circumstances where I am physically unable to consent or am not present:
1. I hereby voluntarily consent to the furnishing to myself, my spouse or any of my said children of such medical care, attention and treatment by any hospital, physician or physicians as such hospital, physician or physicians may deem necessary or advisable.
2. I authorize any officer or member of the Sandy Bay Sailing Program to consent to such medical care, attention or treatment.
3. I agree to pay the reasonable cost of such medical care, attention or treatment and to indemnify and hold free and harmless of and from any and all liability for such cost the Sandy Bay Sailing Program and the United States Sailing Association and its officers and members thereof.
I, the undersigned, do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis or procedure rendered under the general or specific supervision of any member of the medical staff or of a dentist licensed under the provisions of the State Education Law and/or Public Health Law of the State and on the staff of any hospital holding a current operating certificate issued by the State Department of Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power to render care which the aforementioned physician in the exercise of his best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached.
IN CASE OF EMERGENCY CALL:
SIGNATURE OF PARENT/GUARDIAN:____________________________________ DATE: ___________________
PHYSICIAN WHO CONDUCTED YOUR MOST RECENT PHYSICAL EXAMINATION:
|NAME||PHONE NUMBER||DATE OF LAST EXAM|
|HEALTH INSURANCE CARRIER||INSURANCE ID NUMBER|
MEDICAL AND EMERGENCY INFORMATION
NAME: _______________________________________________________ SEX _____(M) _____ (F)
ADDRESS(Street/P.O. Box): ______________________________________________________________________
City __________________________________________________ State _______ Zip_____________
TELEPHONE ___________________ (R) _________________ (B) DATE OF BIRTH: _____________
THE PARTICIPANT AND HIS OR HER PARENTS MUST RESPOND TO THE FOLLOWING QUESTIONS AS ACCURATELY AND COMPLETELY AS POSSIBLE:
Please check those that apply: (Provide necessary details below)
|ASTHMA, OR OTHER RESPIRATORY PROBLEMS||MEDICATION|
|DIABETES OR HYPOGLYCEMIA||BEE STINGS/INSECT BITES|
|HEMOPHILIA, OR OTHER BLEEDING PROBLEMS||FOODS|
|CIRCULATORY OR HEART PROBLEMS|
|EPILEPSY||OTHERS, IF SIGNIFICANT|
DATE OF LAST TETANUS SHOT: ________________________________ BLOOD TYPE: ____________________________
CURRENT MEDICATIONS IF ANY: ________________________________________________________________________
PLEASE MAKE SURE YOU HAVE FILLED IN ALL THE NECESSARY INFORMATION
Sandy Bay Yacht Club, P.O. Box
37, 5 T Wharf, Rockport, MA 01966 USA
(978)546-9433 Clubhouse, (978)546-6240 Office
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