Buzzards Sailing School Emergency Medical Form
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: _________________