Nagawicka Lake Yacht Club Sailing School 2010 (PDF)

____________________________________________ Medical Authorization

( Child's name )

To insure the safety of your children when involved in the NLYC sailing program, we are asking that parents fill out one of the following forms for each child. This form will be required to be on file for anyone participating in any event.

All instructors have been instructed to call 911 in the event of an emergency.

Authorization to Consent to Treatment of Minor

As the legal guardian of the above mentioned sailor, I hereby give consent for emergency medical care prescribed by a duly licensed Physician, Dentist, or other medical care provider. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my dependent.

Family doctor _________________________ Phone ___________________

Dentist          _________________________ Phone ___________________

Persons to contact in emergency:

1.)  ____________________________ Phone ___________________

2.)  ____________________________ Phone ___________________

Medical problems ________________________________________________

Known Allergies __________________________________________________

Hospital insurance plan name and # _________________________________

This authorization shall remain effective until revoked in writing and my child is withdrawn from the NLYC Sailing School activities.

Signature (parent or guardian) _______________________Date:___________

Address _________________________________________________________

Home phone:___________ Work phone:___________ Cell phone:__________

Signature (parent or guardian) ______________________________________

Address ________________________________________________________

Home phone:___________ Work phone:___________ Cell phone:__________