2015 Sailing and Watersports Program
Release and Assumption of Risks Agreement
& Consent for Medical and Dental Treatment
Date: _____________________
General Information:
Participant’s Name: ___________________________
Gender:
o
Age: ______ Date of Birth: ___________
Male:
Telephone: _________________________
Female:
o
Address: ___________________________
Family Physician’s Name:
___________________________________
______________________________
___________________________________
Telephone: ___________________
If Under the Age of 18,
In Case of Emergency Contact:
Name of Parent and/or Guardian:
______________________________
___________________________________
Relationship: _________________
Telephone: _________________________
Telephone: ___________________
Address: ___________________________
___________________________________
___________________________________
~ THIS AGREEMENT AFFECTS YOUR LEGAL RIGHTS;
PLEASE READ IT CAREFULLY AND SIGN ONLY IF YOU
UNDERSTAND AND AGREE TO ITS TERMS ~
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