Adult Learn-to-Sail Registration

Date of Sailing Class

Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Phone (work)

Email*

Sailing Experience*

None
Limited
Can sail alone
Regatta experience

Emergency Contact

Name*

First Last

Phone*

Medical Info

List any medical factors that would be pertinent in emergency treatment.

i.e. allergies, blood type, history of seizures, and any current medication.

Date of last tetanus injection (if known)

Please explain any physical limitations that might prevent you from fully participating in the course.

Can you complete a swimming test?*

Using any stroke, swim approximately 50 yards, tread water for 20 seconds and put on a PDF.

Yes
No

Preferred Family Physician (full name)*

Physician Phone*

Health Insurance

Name of Insurer

Policy Number

IMPORTANT

This part must be complete for attendance.

Permission to Provide Necessary Treatment of Emergency Care:

I hereby give permission to the medical personnel selected by the program director to order x-rays, routine tests, or treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me. If I am unable to communicate and my emergency contact cannot be reached in an emergency, I hereby give permission to the physician selected by the program director to secure and administer treatment, including hospitalization, for me.

Signature*

Date*

Concord Yacht Club