Sailor’s Name ________________________________________
Date of Birth __________
Address _____________________________________________
____________________________________________________
____________________________________________________
Phone ____________ Cell ___________ Email _____________
Please list the person(s) to be notified in case of illness or injury:
Name ____________________ Relationship ______________
Day Phone ____________________ Cell _________________
Name ____________________ Relationship ______________
Day Phone ____________________ Cell _________________
Medical Information
Are there any physical or medical limitations of which we should be aware?
__________________________________________________
__________________________________________________
__________________________________________________
Allergies
__________________________________________________
__________________________________________________
Medications
__________________________________________________
__________________________________________________
Special Needs
__________________________________________________
__________________________________________________
Family physician _____________________________
Telephone # _________________
Medical Insurance _____________________________
Certificate # _________________
Parent/Guardian Consent
Consent is hereby given for the applicant to attend the AYC Junior Sailing Program and permission is given for any emergency medical procedures if they should become necessary.
Signature _____________________________________
Date ____________________
