Jr Sailing Medical Release - Boothbay Harbor Yacht Club

Please complete this form for each Junior Program Participant.

* Participant's Name

Previous participant in Boothbay Region Sailing Team?

Yes

No

BHYC Member Number (if applicable)

* Parent's Name(s)

* Email Address (will be used to share program materials & updates)

* Participant's Date of Birth

* Participant's Height

* Participant's Weight

* Participant's Blood Type

* Date of last tetanus shot

Chronic Ailments (Check all that apply)

Asthma or other respiratory problems

Diabetes or hypoglycemia

Hemophilia or other bleeding problems

Circulatory or heart problems

Epilepsy

Allergies (Check all that apply)

Medications

Bee stings/insect bites

Food

Others, if significant

Current medications, if any

Details

* Health Insurance Carrier

* Policy # and Group Name

* Primary Care Provider

* Phone

Emergency Contacts

* Emergency Contact Name

* Relationship

* Phone

Emergency Contact Name

Relationship

Phone

Emergency Treatment Authorization

I (Parent/Guardian) authorize the staff of the Boothbay Harbor Yacht Club to obtain emergency medical treatment for (Participant) if in their opinion it is needed and none of the above named can be contacted at the time of the emergency.

* Parent/Guardian

* Participant's Name

* Signature of Parent/Guardian

* Date

Releases

* I give permission to my child to travel in a chaperoned parent volunteer vehicle to and from events sponsored and/or sanctioned by the BHYC.

I Do

I Do Not

* I authorize the inclusion of my contact information in a program roster to be shared only with parents whose children attend the Junior Program and for no other purposes.

I Do

I Do Not

* I authorize the release and use of Program-related photographs of my child by BHYC and the Junior Program

I Do

I Do Not

* Signature of Parent/Guardian

* Date

Liability Waiver

I/We understand and acknowledge that participation in the Boothbay Harbor Yacht Club (BHYC) Junior Program may be dangerous and may involve substantial, unforeseen risks to my/our child as well as potentially severe losses or damages arising from those risks and dangers. I/We accept the responsibility for such losses and damages and agree to take appropriate precautions for my/our own safety and that of my/our child and others when participating in the Program. I /We hereby release, waive and discharge BHYC, its coaches, instructors, officials, volunteers, officers, directors, agents and employees engaged by the BHYC, in conduct of the Program and related activities from all liability to me/us and or my/our child and all claims, demands losses or damages on account of any injury, death or damage to property, arising out of my/our child’s participation in the Program, whether on the BHYC premises or elsewhere, including transportation to and from events and venues.

* Signature of Parent/Guardian

* Date

* Denotes Required Field