HomeEventsJr SailInformationLinksMembers OnlyRacingSpreader

Medical Release Form

Please complete all required fields below and then be sure to press the SUBMIT button located at the bottom of this form.

Personal Information
Student Name:
Date of Birth: Age: Sex:
Physical Handicaps:
Psychological Handicaps:
Learning Problems:

Chronic Ailments
Asthma or other respiratory problems
Diabetes or hypoglycemia
Circulatory or heart problems
Epilepsy
Known allergies
Hemophilia or bleeding problems
Current Medications, if any
Date of last tetanus shot (mm/dd/yyyy)

Health Care Information
Preferred Physician
Physician Phone
Emergency Hospital Care Preference
Name of Health Insurance Policy
Family or friends to be contacted in case of an emergency:
 (name, relationship,phone)

1.
2.
3.

Treatment Authorization

The undersigned parent or guardian of a minor, do hereby consent to any emergency x-ray, anesthetic medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any licensed physician or surgeon.

It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable; and neither said agent or any organization involved assumes any financial responsibility for exercising this action.

This authorization shall remain effective until revoked in writing.
  

Signature (Parent or Guardian)
Date
Home Phone
Business Phone:


Note your will have to come by before class begins and sign the forms.

You can provide feedback on this website by submitting email to the webmaster or the commodore. You can mail directly to the Yacht Club at: Pensacola Beach Yacht Club, PO Box 1112, Gulf Breeze, FL 32562 - 1112. Phone (850) 934-8757. See our Location page for more information