LCYC 2005 Junior Sailing Program

 Confidential Medical Information

Student’s Name: Last_______________________First_________________________MI____________________
Date of Birth ______________________________  

Known Allergies:                                                               Please mention any food allergies as we do occasionally offer food to the children.

 

Medical Concerns:                                                         

 

Persons to contact in case of emergency:

1.  Name__________________________________   Relationship___________   Phone ____________

2.  Name _________________________________    Relationship __________    Phone ____________  

Physician Name: ______________________________________  Phone: ___________________  
Date of last tetanus shot _________________________________________________________

Anything else we should be aware of: _______________________________________________

  

 PARENT/GUARDIAN EMERGENCY TREATMENT AUTHORIZATION:

 I, _________________________(Parent/Guardian), authorize the program organizers or their employees to provide emergency treatment, if required, and authorize them to contact one of the above-named persons.

 Date: _________________     Signature: _____________________________________

  

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