NLSS Medical, Emergency, Hold Harmless Information-Summer 2017
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 address
Sailor's First Name
Your answer
Sailor's Last Name
Your answer
Street Address
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Date of Birth
MM
/
DD
/
YYYY
FIRST Emergency Contact
Please type first and last name
Your answer
FIRST Emergency Contact's relationship to sailor
FIRST Emergency Contact's FIRST Phone Number to call
Format=> ###-###-####
Your answer
FIRST Emergency Contact's SECOND Phone Number to call
If none, type=> none. Otherwise format=> ###-###-####
Your answer
SECOND Emergency Contact
Please type first and last name
Your answer
SECOND Emergency Contact's relationship to sailor
SECOND Emergency Contact's FIRST Phone Number to call
Format=> ###-###-####
Your answer
SECOND Emergency Contact's SECOND Phone Number to call
If none, type=> none. Otherwise format=> ###-###-####
Your answer
Do you have another contact or other special instructions?
If none, please type "none."
Your answer
Please List Allergies
If none, please enter "none."
Your answer
Medications: What do we need to know?
Name, Dosage, Form, Time taken & Reason. Info regarding EpiPen or Inhaler. Otherwise type "none"
Your answer
Does the sailor have significant health or medical concerns?
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."
Your answer
Other Notes:
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.
Your answer
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.
Your answer
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
Your answer
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
Your answer
Current Team
Required
Check all that apply: I participate in the following activities
Required
Have you ever had a concussion?
If you answered yes to having a concussion, how many times?
If you answered no, type 'n/a'
Your answer
Have you ever experienced concussion symptoms?
If you answered yes to having a symptoms, did you report them?
If you answered no, type 'n/a'
Your answer
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