Child's Name__________________________________________________  Sex (M or F)_______
      
Date of birth_________________________________ Height____________  Weight__________         

Special conditions (Specify injuries, weaknesses, eyeglasses, contacts, hearing aid,
anxieties, fears, hyperactivity, learning disabilities, etc.):

____________________________________________________________________________________                                                                                           ____________________________________________________________________________________

____________________________________________________________________________________                                                                      

Please check those that apply and provide necessary details on the reverse side of 
this sheet.

Chronic ailments:  _____ Asthma or other respiratory problems
                   _____ Circulatory or heart problems
                   _____ Diabetes or hypoglycemia
                   _____ Hemophilia or other bleeding problems
                   _____ Epilepsy

Allergies:         _____ Bee stings or other insect bites
                   _____ Foods
                   _____ Others, if significant

Date of last Tetanus shot:__________________ 

Current medication(s) if any:______________________________________________________

Preferred personal or family physician:  Name:_____________________________________

                                        Phone:_____________________________________                                                      

Health Insurance Company:_______________________________________________________

Policy #___________________________________________

Emergency contacts:          Name               Relationship     Phone

	1.___________________________________  ______________  ________________

	2.___________________________________  ______________  ________________

	3.___________________________________  ______________  ________________                                                                                      


I, the undersigned parent/guardian, authorize the Buzzards Yacht Club organizers or
staff members to sanction emergency treatment if a parent/guardian listed above can
not be contacted at the time of an emergency. 

Signature: ________________________________  Date: _________________