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Home > Sailing > Chartering Seaview Mermaids > Medical Form
Home > Sailing > Chartering Seaview Mermaids > Medical Form

Medical Form

305766_1124x

Doctor’s name: …………………………………………………….. Tel: ………………………………………….

Have you ever suffered from any of the following conditions:

Asthma/bronchitis Yes No

Heart conditions Yes No

Fits, fainting or blackouts Yes No

Severe headaches Yes No

Diabetes Yes No

Travel sickness Yes No

Allergies to medication Yes No

Any other allergies Yes No

Other illnesses or disabilities Yes No

If you have answered Yes to any of the above, please provide details in the box below.

Are you currently taking any medication? If so, please specify.

Are you suffering / recovering from any injuries which may affect your sailing?

Are you vegetarian? Yes No

Do you have any food allergies? If so, please specify.

Signed: ………………………………………………………………….

Counter Signed: …………………………………………………………………. (by parent/guardian of under 18)

Consent

Sea View Yacht Club

Medical Disclosure and Consent Form

In an emergency situation I authorise the organisers to take my son/daughter to hospital and give my full permission

for any treatment required to be carried out in accordance with the hospital’s diagnosis. I understand that I shall be

notified, as soon as possible, of the hospital visit and any treatment given by the hospital.

I the parent/guardian of …………………………………………………………… give permission to the Sea View Yacht Club

during…………………………………………………….. (dates of event) to administer any relevant treatment or medication to the

above named participant when or if necessary.

Name: ………………………………………………………………………………………….

Date of birth: ………………………………..

Mobile: ……………………………………………………..

CONFIDENTIAL

It is your responsibility to make known any potential medical conditions that may affect you during the activities

associated with the training programme or event you are taking part in. Please therefore provide as many details as

possible. This information will be shared with the organisers and coaches at training and events.

Next of kin: …………………………………………………..  Relationship: ………………………..

Home: ………………………………………………………

Work: ………………………………………………………

Age: …….

Emergency contact numbers for next of kin: (or…………………………………………………………….contact details)

If under 18: Mum’s Mobile: ……………………………………………………… Dad’s Mobile: ………………………………………………….

Last updated 14:45 on 15 March 2017

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