Lake
Jr. Sailing Program
Medical Emergency Form
Student’s Name:
___________________________________________DOB________________________
Parent’s Names: _______________________________________________________________________
Address:
_____________________________________________________________________________
Home Phone:
__________________________________
Cell:_____________________________
Mother’s Work Phone:
_______________________________
Father’s Work Phone:________________________________ Cell:_____________________________
Emergency Contact Name:____________________________
Relationship:________________________
Contact Address:
_______________________________________________________________________
Daytime Phone(s):
_____________________________________________________________________
Family Physician:
______________________________________Phone:___________________________
Family Dentist:________________________________________
Phone:___________________________
Medical Insurance Company:
______________________________________________________________
Name of Policyholder:____________________________________________________________________
Policy/Group Number:
___________________________DOB ___________________
Allergies (medications,
insect stings, food, etc.): _______________________________________________
Date of last tetanus Shot:
_________________________________________________________________
Disability or chronic
illness: _______________________________________________________________
Any
specific activities to be restricted:
_______________________________________________________
Student
is under care of a physician for the following condition(s):
________________________________
Emergency Authorization: This health
history is correct to the best of my knowledge.
The above student’s immunizations are up to date. Student listed above has permission to engage
in all activities except as noted herein.
In the event I cannot be reached in an emergency, I hereby give
permission to the physician selected by the LHYC representative to hospitalize,
secure proper treatment, order x-rays, routine tests, injections and/or
anesthesia and/or surgery for the student listed above.
____________________________________________________________ _____________________
Signature of Parent or Legal
Guardian Date