Medical Release Form printable pdf download

Please bring this form on the first day of sailing school

NOTE: You will not be able to participate until this medical release form is in the PMYC clubhouse

Medical Release Form and Code of Conduct Agreement

Student’s Name(s):

Parent/Legal Guardian’s Name:

Phone #’s (please include home and cell numbers)

HOME:

CELL:

OTHER:

Physician’s Name:

Physician’s Phone #:

Primary Insurance Company:

ID#:

Group #:

Statement of Consent: In the event of an emergency or non-emergency situation requiring medical

treatment, I, ________________________________, hereby grant permission for any and all

medical and/or dental attention to be administered to my child/children, in the event of an accidental

injury or illness, until such time as I can be contacted. This permission includes, but is not limited to,

the administration of first aid, the use of an ambulance, and the administration of anesthesia and/or

surgery, under the recommendation of qualified medical personnel.

Parent/Guardian Signature

Date

CODE OF CONDUCT:

Sailing school participant: I have read, understand, and will abide by ALL of the rules and

conditions of the PMYC Junior Sailing Program Code of Conduct.

________________________________________________________________________

Sailing School Participant Signature

Date

Parent or Guardian: I am the parent/guardian of the above named sailing school participant. I

understand that if my child fails to comply with the Code of Conduct, he/she may be sent home. I

agree to provide transportation in that event. I agree to the rules and conditions of the Code of

Conduct and give my child permission to participate in the Sailing Program:

________________________________________________________________________

Parent/Guardian Signature

Date

Medical Release Form