NLSS Medical, Emergency, Hold Harmless Information-Summer 2017

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This form provides the North Lake Sailing School with the medical, release and liability information needed for all of the 2017 Summer sailing programs.

ONE FORM FOR EACH SAILOR (only one even if in more than one type of class)

Please note that you will have to complete the form and SUBMIT at the end before the information is actually sent to us. If you close the form before submitting, you will have to start over.

Email *

Sailor's First Name *

Sailor's Last Name *

Street Address *

City *

State *

Zip *

Date of Birth *

YYYY

FIRST Emergency Contact *

Please type first and last name

FIRST Emergency Contact's relationship to sailor *

Mother

Father

Grandparent

Other:

FIRST Emergency Contact's FIRST Phone Number to call *

Format=> ###-###-####

FIRST Emergency Contact's SECOND Phone Number to call *

If none, type=> none. Otherwise format=> ###-###-####

SECOND Emergency Contact *

Please type first and last name

SECOND Emergency Contact's relationship to sailor *

Mother

Father

Grandparent

Other:

SECOND Emergency Contact's FIRST Phone Number to call *

Format=> ###-###-####

SECOND Emergency Contact's SECOND Phone Number to call *

If none, type=> none. Otherwise format=> ###-###-####

Do you have another contact or other special instructions? *

If none, please type "none."

Please List Allergies *

If none, please enter "none."

Medications: What do we need to know? *

Name, Dosage, Form, Time taken & Reason. Info regarding EpiPen or Inhaler. Otherwise type "none"

Does the sailor have significant health or medical concerns? *

None

Asthma/Other Respiratory Problems

Diabetes or Hypoglycemia

Circulatory or Heart Problems

Seizure Disorder

Other:

Required

Please add any other information about your sailor that you feel would be important for NLSS Instructors to know *

If none, please enter "none."

Other Notes: *

None

Vision Impaired-wears contacts/glasses

Hearing Impaired

Other:

Required

Medical Consent and Release Waiver

I authorize and give consent to the North Lake Sailing School (NLSS) instructors, coaches and any of NLSS's representatives to seek and administer to myself, my child or any family member, any and all medical and hospital care, treatment and attention appropriate and necessary in the event of accident, injury, or sickness, until such time that I can be contacted.

I, the undersigned, understand that every effort will be made to contact me and the emergency contacts listed prior to initiating care, but treatment will not be withheld if contact cannot be made, as to insure the well being of my child.

I, the undersigned, certify that I am the parent or legal guardian of the participant. I also will be responsible for any and all costs associated with such necessary medical attention and/or treatment, including but not limited to transportation required for treatment.

Parent/Guardian Electronic Signature. *

I have read the above statement and indicate my agreeement with my FIRST and LAST name.

Hold Harmless Release Waiver

By registering my child with the North Lake Sailing School (NLSS), I acknowledge that there are dangers and risks of injury and/or property damage inherent in this activity, but I still desire my child to participate.

I agree to participate and allow my child to participate in the NLSS activities while in, on or about the premises of the North Lake Yacht Club (NLYC) or while participating in any activity sponsored by or under the auspices of the NLSS or NLYC, and hereby release NLSS and NLYC, their officers, directors, employees, agents and representatives, from liability for any personal injuries and/or property damage resulting from any accident or any event arising out of the sailing School activities that might occur to myself or to my child and family members while participating in NLSS programs.

I do hereby indemnify and hold harmless the above mentioned organizations and/or individuals, their agents and/or employees, against any and all claims, actions, causes of actions, and any and all liablity for personal injury, including injuries resulting in death to me, my child and/or other family members, or damage to my property, the propety of my child and/or other family members, or both, while I or my child and/or family members participate in this NLSS program.

I, the undersigned, certify that I am the parent or legal guardian of the participant. This authorization is valid for the 2017 season.

Parent/Guardian Electronic Signature. *

I have read the above statement and indicate my agreeement with my FIRST and LAST name.

Concussion Agreement for Students and Parents

This relates to Concussion Law WI Stat. 118.293

As a Parent and as an Athlete it is important to recognize the signs, symptoms, and behaviors of concussions. By signing this form you are stating that you understand the importance of recognizing and responding to the signs, symptoms, and behaviors of a concussion or head injury. This form must be on file for every sports season and every youth athletic organization the athlete is involved with and must therefore be renewed each sailing school year (every 365 days)

Please review the "Know your Concussion ABC's". There is one for the Athlete and one for the Parents. The web address is found below by each agreement. Also you can link to the PDF forms from the www.nlss.us web page Registration tab.

Athlete Agreement

I have read the Athlete Concussion and Head Injury Information and understand what a concussion is and how it may be caused.
http://sped.dpi.wi.gov/sites/default/files/imce/sped/pdf/tbi-conc-facts-athletes.pdf

Here is the Information

I understand the importance of reporting a suspected concussion to my coaches and my parents/guardian.

I understand that I must be removed from practice/play if a concussion is suspected. I understand that I must provide written clearance from an appropriate health care provider to my coach before returning to practice/play.

I understand the possible consequence of returning to practice/play too soon and that my brain needs time to heal.

Student Sailor Electronic Signature *

First and Last name

Parent Agreement

I have read the Parent Concussion and Head Injury Information and understand what a concussion is and how it may be caused. I also understand the common signs, symptoms, and behaviors. I agree that my child must be removed from practice/play if a concussion is suspected.
http://sped.dpi.wi.gov/sites/default/files/imce/sped/pdf/tbi-conc-facts-parents.pdf

I understand that it is my responsibility to seek medical treatment if a suspected concussion is reported to me.

I understand that my child cannot return to practice/play until providing written clearance from an appropriate health care provider to his/her coach.

I understand the possible consequences of my child returning to practice/play too soon.

Parent/Guardian Electronic Signature *

First and last name

Current Team *

North Lake Sailing School

Required

Check all that apply: I participate in the following activities *

Football

Soccer

Track & Field

Gymnastics

Baseball/Softball

Golf

Cross Country

Tennis

Basketball

Volleyball

Cheerleading

Swimming & Diving

Hockey

Wrestling

Skiing/Snowboarding

Other:

Required

Have you ever had a concussion? *

Yes

If you answered yes to having a concussion, how many times? *

If you answered no, type 'n/a'

Have you ever experienced concussion symptoms? *

Yes

If you answered yes to having a symptoms, did you report them? *

If you answered no, type 'n/a'

Send me a copy of my responses.

Submit

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