Participant Medical Release & Responsibility Form
ROYAL PRINCE ALFRED YACHT CLUB
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
A valid phone number throughout the event.
Team / Yacht Club Representing
*
Australian Sailing or National Authority Member Number:
*
https://www.sailing.org.au/member-finder/
Medical Information
Date of birth
*
-
Day
-
Month
Year
Date
Please check if any of the following Medical Conditions apply:
Allergies
Asthma
Epilepsy / Seizures
Heart Disease
Injuries
Low Blood Pressure
Vision or Hearing Impairment
Wearing Contact Lenses
Allergies
Please list any allergies.
Epilepsy / Seizures
Please list any information to assist our staff.
Injuries
Please list any injuries you currently have that may limit your ability to participate.
Vision or Hearing Impairment
Please describe any impairment that may limit your ability to participate.
Other medical conditions / details:
Special dietary requirements:
Do you have private medical insurance?
Please Select
Yes
No
Do you have travel insurance?
Please Select
Yes
No
In case of incident, please notify:
Emergency Contact Name:
*
Emergency Contact Relationship:
*
Emergency Contact Phone:
*
Emergency Contact Email:
*
Participant Medical Release & Responsibility
Medical Release
I, the undersigned, do hereby authorise and give consent for the participant to compete in the above mentioned regatta and if required consent to medical treatments to be applied, if recommended or required I consent to been taken or to hospital/medical Centre and or for an Ambulance to be contacted. [RPAYC policy for any head injury is to contact the Ambulance Service]. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. It is understood that in the event of medical treatment being authorised by the Club or its duly authorised agent that I will indemnify the Royal Prince Alfred Yacht Club from any consequence arising there from (including the payment of medical expenses).
Drugs & Alcohol
Participants must not consume alcohol whilst taking part in racing or onboard RPAYC vessels. Participants under the age of 18 years must not consume any alcohol at all times throughout the event, and on Royal Prince Alfred Yacht Club premises. Consumption any illegal or improper drug will not be tolerated either during the day or evening activities. Competitors are reminded of RRS 6.
Representation
Participants are reminded that they are representatives of their home club. Participants are to treat the club facilities, members & guests, with the utmost respect. Disrespectful behaviour will not be tolerated.
Agreement
*
I have read and agree to the above items, and agree to undertake these responsibilities.
Signature of Participant
Name of parent / guardian (if under 18 years of age)
Signature of parent / guardian (if under 18 years of age)
Submit
Should be Empty: