ILYC Medical Form - Ida Lewis Yacht Club

ILYC Medical Form

ILYC Medical HIstory release Form

MEMBER REGISTRATION BEGINS FEBRUARY 1ST
NON-MEMBERS BEGIN MARCH 1ST, REGISTRATIONS SUBMITTED BEFORE THESE DATES WILL NOT BE VALID
NOTE: NON-MEMBERS NEED A MEMBER SPONSOR TO BE INCLUDED IN THEIR REGISTRATION

IDA LEWIS YACHT CLUB JUNIOR SAILING PROGRAM
MEDICAL HISTORY & RELEASE
**Please complete one form for each participating child in the family.**

Junior Sailor Name:

Mother:

Father:

Home Phone Number:

Work Phone number:

Work Phone Number:

Cell Phone Number:

Parent Email:

Member Number (if applicable):

Address:

Summer Address (if different):

Emergency Contact Name:

Emergency Contact Relation:

Emergency Contact Home Phone:

Emergency Contact Work Phone:

Emergency Contact Cell Phone

My child is healthy and may participate in all activities related to the Junior Sailing Program

Parent/Guardian Signature (Please Click and Drag with your Cursor or Finger to Sign):

Child's Physician:

Physician's Phone Number:

Medications:

Allergies:

Other medical conditions or concerns: (recent surgery, asthma or other breathing problems, hemophilia or other bleeding problems, seizures, diabetes, etc.):

Is there anything we should know that can make this a fun and happy summer for your child?

Medical Insurance Information: Parent/Guardian’s Insurance Coverage:

Policy Holder:

Carrier:

Policy #:

Group #:

Please check the box to confirm that you have read and acknowledge the following documents.

Sailor and Parent Code of Conduct

Junior Sailing Explanation of Discipline

Parent Volunteer Name:

Type of Volunteering:

Other:

PARENT/ GUARDIAN EMERGENCY TREATMENT AUTHORIZATION
I hereby grant permission to any appropriately qualified health care professional to give any and all medically appropriate emergency care to my son/daughter/ward, including but not limited to anesthesia and surgery.

Signature (Please Click and Drag with your Cursor or Finger to Sign):

Saving Information...Please Wait