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Youth Medical Form

This form must be completed for all participants who are under 18 years of age.

Name: *
Date of Birth: *
Age: *
Sex: *
Name of Parent or Guardian: *
Home Address: *
City: *
State: *
Zip: *
Home Phone: *
Cell Phone: *
If the person above is not available in the event of an emergency, notify:
Emergency Contact Name #1: *
Relationship: *
Phone: *
Emergency Contact Name #2: *
Relationship: *
Phone: *
Name of Personal Physician: *
Phone: *
Health/Accident Insurance Carrier: *
Policy Number: *
Initials of Acceptance (Parent or Guardian): *
In the case of emergency, I understand every effort
will be made to contact me. In the event I cannot be
reached, I hereby give my permission to the physician
selected to secure the proper medical treatment, which
may include hospitalization, anesthesia, surgery or
injection of medication for my son/daughter. By placing
my initials in this box I agree to the statements.
Medical Information:  
Heart Disease
High Blood Pressure
Other (Describe Below)
past or present information / check all that
apply and provide necessary details
Medical Explanations:  
Insect Bites
please check all that apply and provide necessary details
Allergy Explanations:  
Special Equipment?:  
such as orthopedic or handicap devices,
glasses or contacts, dentures
Special Equipment Explanation:  
Date of Last Tetanus Shot:  
  * indicates required information

First Name: (leave this field blank)
Last Name: (leave this field blank)
P.O. Box 2424, Nantucket, MA 02584
Office: 508-228-6600 / Jetties Beach: 508-228-5358
© 2015 Nantucket Community Sailing, a 501(c)(3) non-profit organization