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PORT CLINTON YACHT CLUB SAIL PROGRAMS EMERGENCY MEDICAL AUTHORIZATION FORM PURPOSE: To enable parents and/or guardians to authorize the provision of emergency treatment for children who become ill or injured while participating in the PCYC Learn to Sail, and/or Jr. Race Program(s). Participant’s Name: ______________________________________ Age ______ Grade in Fall ___________ Address


State _____ Zip _____________

Phone (____)__________________ Father

Usual Work Hours

Place of Employment




Usual Work Hours

Place of Employment



PART I In the event of an accident by participant reasonable attempts to contact either parent and/or guardian list above, or: 1.

___________________________________________ Name

____________________ ________________________ Relationship Phone


____________________________________________ ____________________ ________________________ Name Relationship Phone

will be made. Instructors will notify emergency medical personnel for transfer to the hospital if necessary. Dr.

(Preferred Physician) Phone Or


(Preferred Dentist)


or in the event the designated preferred practitioner is not available, by another licensed physician or dentist; or (2.) transfer of my child to ____________________________________________ (Preferred hospital), or any hospital reasonably accessible. This authorization does not cover major surgery. I do hereby give my consent for emergency medical treatment of my child in the event of illness or injury. Date

Parent’s Signature


Parent’s Signature

MEDICAL HISTORY: Facts concerning my child’s medical history including allergies, medications, and physical impairments to which a physician should be alerted:

______________________________________________ Date of Last Tetanus Shot

MEDICAL INSURANCE INFORMATION: Medical Insurance Coverage With: _______________________________________________________________ Group Policy # ___________________________ Plan # _________________________ Eff. Date ____________

DO NOT COMPLETE PART II IF YOU COMPLETED PART I PART II – REFUSAL TO CONSENT I do not give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the instructor to take no action or to:

Dated ________________________ Parent Signature _______________________________________________

Emergency Medical Forms  
Emergency Medical Forms  

medical forms