Nantucket Community Sailing - Youth Medical Form

Name: *

Date of Birth: *

Age: *

Sex: *

Name of Parent or Guardian: *

Home Address: *

City: *

State: *

Zip: *

Home Phone: *

Cell Phone: *

If the person above is not available in the event of an emergency, notify:

Emergency Contact Name #1: *

Relationship: *

Phone: *

Emergency Contact Name #2: *

Relationship: *

Phone: *

Name of Personal Physician: *

Phone: *

Health/Accident Insurance Carrier: *

Policy Number: *

Initials of Acceptance (Parent or Guardian): *

In the case of emergency, I understand every effort
will be made to contact me. In the event I cannot be
reached, I hereby give my permission to the physician
selected to secure the proper medical treatment, which
may include hospitalization, anesthesia, surgery or
injection of medication for my son/daughter. By placing
my initials in this box I agree to the statements.

Medical Explanations:

Allergy Explanations:

Special Equipment?:

such as orthopedic or handicap devices,
glasses or contacts, dentures

Special Equipment Explanation:

Date of Last Tetanus Shot:

* indicates required information

First Name: (you must leave this field blank)
Last Name: (you must leave this field blank)