MBJA.org | Medical Consent Form

Personal Information

First Name * Last Name * Address * City * State * Zip Code *

Emergency Contacts

First Name * Last Name * Relationship * Phone * First Name * Last Name * Relationship * Phone *

Physician Information

Physician Name * Date of Last Exam * Office Phone *

Insurance Information

Insurance Carrier * ID Number *

If child is not insured please enter "N/A"

Medical Information

Chronic Ailments (check all that apply)

Asthma, or other respiratory problems Diabetes or hypoglycemia Hemophilia, or other bleeding problems Circulatory or heart problems Epilepsy

Allergies (check all that apply)

Asthma, or other respiratory problems Diabetes or hypoglycemia Hemophilia, or other bleeding problems Other Allergies

Current Medications (if any)

Other Information

Date of Last Tetanus Shot * Blood Type *

NOTE: By proceeding to checkout you thereby agree to our terms.

Terms

Double-handed skippers and crews must EACH complete and sign separate copies of this form.

In the event of accident or injury to myself, my spouse or any child of mine (specifically including my child named above as "Participant") or in the event of illness of myself, my spouse or any child of mine while on or about the premises of the Host Club/Organization while participating in an event under the auspices of the Host where I am unable to consent or am not present:

I hereby voluntarily consent to the furnishing to myself, my spouse or any child of mine of such medical care and treatment by any hospital or physician(s) as the hospital or physician(s) deem necessary or
I authorize any officer or member of the Host to consent to such medical care or treatment.
I agree to pay the reasonable cost of such medical care or treatment and to indemnify and hold free and harmless of all liability for such cost the Host and US SAILING and its officers and members.

I hereby authorize any x-ray examination, anesthetic, medical or surgical diagnosis or procedure supervised by any member of the medical staff or of a dentist licensed under the State Education Law and/or Public Health Law of the State and of the staff of any hospital holding a current operating certificate issued by the State Department of Health. This authorization is given in advance of any specific diagnosis, treatment or hospital care being required in order to provide authority to render care which the aforementioned physician in his best judgment may deem advisable. Effort shall be made to contact me before rendering treatment to the patient, but any of the above treatment will not be withheld if I cannot be reached.