2022 SHYC JR: Medical, Emergency Contact, Permission to Treat, Contact Info
Please complete this form to authorize emergency treatment for your child for the SHYC Junior Programs.
Sign in to Google to save your progress. Learn more
Email *
Participants/Child Name *
Date of Birth *
MM
/
DD
/
YYYY
Street Address *
City *
State *
ZIP *
Alternative Email *
Gender *
FOR SAILING PROGRAM PARTICIPANTS ONLY: Check the "YES" box below to authorize SHYC to provide your child's contact information (name, DOB, gender, parent email, parent cell, mailing address) to US SAILING to create a JR US SAILING Membership and Skill-UP account for your child to use as part of the Sailing Program at SHYC. Learn more at: https://www.ussailing.org/membership/organizations/skill-up/ *
Required
Height (inches) *
Weight (lbs) *
US SAILING: If you have a Family US SAILING Membership or your child is a Youth Member of US Sailing, indicate US Sailing Member # here. If you don't know, or are not a USS member, skip this question.
Please list any current or past medical problems: *
Surgical History: *
List all Allergies (Medication, Foods,  Bees, Wasps, Jelly Fish, or more): *
Current Medication Taken: *
Date of last Tetanus shot: *
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of sachemsheadyc.com. Report Abuse