LAKE HOPATCONG YACHT
CLUB
2010 JUNIOR SAILING
PROGRAM
MEDICAL EMERGENCY FORM
(Please print clearly)
Sailor’s Name: _____________________________________________________
DOB: _______________________
Parent’s Names: ________________________________________________________________________________
Address:
______________________________________________________________________________________
_____________________________________________________________________________________________
Home Phone: _____________________________________ Mother’s
Cell: _________________________________
Mother’s Work: ___________________________________ Father’s
Work: ________________________________
Father’s Cell: ______________________________________
Additional Phone: _____________________________
Emergency Contact Name: ______________________________________
Relationship: ______________________
Emergency Contact Home phone: _____________________ Emergency
Contact Cell: ________________________
Family Pediatrician: _______________________________________
Phone: _______________________________
Family Dentist: ___________________________________________ Phone:
_______________________________
Medical Insurance Company: _____________________________________________________________________
Name of Policyholder: ____________________________________________
DOB: __________________________
Policy/Group Number:
___________________________________________________________________________
Allergies (Food, Medications, Insect stings,
etc…):_____________________________________________________
_____________________________________________________________________________________________
Date of Last Tetanus shot:
________________________________________________________________________
Disability or chronic illness:
_______________________________________________________________________
Any specific activities to be restricted:
______________________________________________________________
_____________________________________________________________________________________________
Student is under care of a physician for the following
condition(s): _______________________________________
_____________________________________________________________________________________________
Emergency Authorization: The
health history is correct to the best of my knowledge. The above student’s immunizations are up to
date. Student listed above has
permission to engage in all activities except noted herein. In the event I cannot be reached in an
emergency, I hereby give permission to the physician selected by the LHYC
representative to hospitalize, secure proper treatment, order x-rays, routine
tests, injections and/or anesthesia and/or surgery for the student listed
above.
Parent/Guardian Print Name______________________________________________________________________
Parent/Guardian Signature:
__________________________________________ Date: _______________________