Medical & Emergency Info Form

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Personal Information

Participant's Name

First

Last

Date of Birth

Home Address

Gender

Phone Number

Medical Information

Do you have a history of or do you currently have, any physical limitations that might prevent you from fully participating in this Sailing Camp?

If yes, please specify missing or injured body parts, weakness, eyeglasses, contacts, hearing aids, etc.

Do you have any learning disabilities that might prevent you from fully participating in this course?

If yes, please specify

Physician Name

Physician Phone

Current Medications

Blood Type

Date of last tetanus shot

Physician Email

Known Allergies

Existing Conditions

Chronic Ailments

Asthma, or other respiratory problems Circulatory or heart problems
Diabetes or hypoglycemia
Epilepsy
Hemophilia, or other bleeding problems

Insurance Information

Insurance Provider

Policyholder's Name

Where are your medical records kept?

Policy Number

Date of most recent physical exam?

Emergency Contact

Contact Name

Contact Email

Relationship to Child

Contact Phone

Contact Name 2

Relationship to Child

Contact 2 Email

Contact 2 Phone

Consent and Signature

Checkboxes

I consent to medical treatment as described:

In the event of accident or injury to myself, my spouse, or any child of mine (specifically including my child named above as "Participant") or in the event of illness of myself, my spouse, or any child of mine while on or about the premises of Fort Walton Yacht Club while participating in an event under the auspices of Emerald Coast Sailing Association (ECSA) and Fort Walton Yacht Club (FWYC) where I am unable to consent or am not present:

1. I hereby voluntarily consent to the furnishing to myself, my spouse, or any child of mine of such medical care and treatment by any hospital or physician(s) as the hospital or physician(s) deem necessary or advisable.
2. I authorize any officer or member of the Host to consent to such medical care or treatment.
3. I agree to pay the reasonable cost of such medical care or treatment and to indemnify and hold free and harmless of all liability for such cost ECSA, FWYC, and US SAILING and its officers, volunteers and members.

I, the undersigned, do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis, or procedure rendered under the general or specific supervision of any member of her medical staff or a dentist licensed under the provision of the Education Law and/or Public Health Law of the State of FLORIDA and on the staff of any hospital holding a current operating certificate issued by the Department of Health of the State of Florida. It is understood that the authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power to render care which the aforementioned physician in the exercise of his/her best judgment may deem advisable. It is understood that effort shall be made to contact the above people before rendering treatment to the patient, but that any of the above treatments will not be withheld if any of these people cannot be reached. No agent or organization involved assumes any financial responsibility for exercising this action

Signature

Clear Signature

Parent/Guardian Name

a Phone injured

Parent/Guardian Email

Date of Signature