2018 Junior Sailing Program Medical/ Emergency Release and Information Form
Email address *
2018 Junior Sailing Program Medical/Emergency Release and Information Form
Student's Name *
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Student's Nickname, if any
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Age *
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Birthdate *
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Gender *
Home Phone *
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Work Phone *
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Cell Phone *
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Emergency Contact Person's Name (Other than Parent/Guardian) *
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Emergency Contact Phone Number (Other than Parent/Guardian) *
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Medical Conditions *
Allergies *
If food allergies, list foods: *
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Medications, please list, including dosages: *
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Does the Student Carry an Epipen? *
Date of Last Tetanus Shot *
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Name of Student's Physician *
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Physician's Phone Number *
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Name of Student's Dentist *
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Dentist's Phone Number *
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Health Insurance Company Name and Insurance Number *
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WAIVER: Parent/Guardian is not aware of any risk that the activities undertaken in the Junior Sailing Program will aggravate any of the Student's existing health conditions. Parent understands that in case of an emergency JPYC will make a reasonable attempt to contact the Parent/Guardian. In the event that contact is not possible the Parent/Guardian authorizes JPYC to take all necessary emergency action (including, without limitation, transport to nearest emergency center), and medical personnel to take all necessary action (including, without limitation, x-rays, exams, anesthesia, medical and surgical care). The Parent/Guardian hereby fully releases, forever discharges and indemnifies JPYC, the JPYC Foundation, any and all race sponsors, and their respective officers, directors, employees, contractors, volunteers, agents and representatives from any and all liability, of whatsoever nature, which the Parent/Guardian and/or Student may now or in the future have for any reason whatsoever in connection with the Student's participation in JPYC and/or JPYC Foundation's activities/events and/or use of their equipment/facilities. *
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