SATUIT BOAT CLUB

Junior Sailing Program 2005 – Medical Form

 

Sailor’s Name____________________________________  Date of Birth______________________  Sex_____

 

In the event of an emergency, notify:

First Contact:  Name________________________________________Relationship:_______________________ Home phone________________­­­_______ Work Phone____________________ Other Phone_______________

 

Second Contact:  Name_____________________________________Relationship:  _____________________  Home Phone_______________________  Work Phone___________________  Other Phone_______________

                                               

Health Insurance Carrier:_______________________________  Member Name:________________________

Sailor’s ID #:______________________________________________

 

Allergies_______________________________________________________________________________________

 

Special medical problems/medications__________________________________________________________

________________________________________________________________________________________________

 

Other Considerations __________________________________________________________________________

_______________________________________________________________________________________________

 

            Vaccine                                      Inoculation Date                                    Booster Date

 

            Measles                                     ________________                                    ____________

            Mumps                                      ________________                                   

            Rubella                                     ________________

            Polio                                         (1)_____________            

                                                            (2)_____________

                                                            (3)_____________                                     (4)___________

            DPT                                          (1)_____________

                                                            (2)_____________

                                                            (3)_____________

            Separate Tetanus                       ________________

 

PHYSICIAN’S CERTIFICATE

 

I certify that_______________________ has received a physical examination within one year prior to participation with the SBC Junior Sailing Program.  Any conditions that would preclude or limit this sailor’s participation are listed above.

 

Physician’s Signature__________________________________________________________  Date___________

Physician’s  Name: _____________________________________________________________________________

              Address:______________________________________________________________________________

                 Phone:______________________________________________________________________________

PLEASE COMPLETE ONE FORM FOR EACH STUDENT