CISF Medical Release & Liability Waiver, 2022

CISF Medical Release & Liability Waiver, 2022

Up to 4 children in the same family can be on a single waiver
Participant Name *

First Name Last Name
Participant Name

First Name Last Name
Participant Name

First Name Last Name
Participant Name

First Name Last Name
Parent/Guardian Name *

First Name Last Name
Parent/Guardian Number *
Please enter a valid phone number.
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact #1 *

First Name Last Name
Emergency Contact #1 Phone Number *
Please enter a valid phone number.
Emergency Contact #2

First Name Last Name
Emergency Contact Phone Number #2
Please enter a valid phone number.
Physician Name *
Physician Phone number *
Health Insurance Information - Name of company, Policy & group # *
Medical or other problems that staff should be aware of, i.e. allergies?
My child/children will commute by:

Car Bicycle Walk Other
Person(s) authorized to pick up my child(ren) other than those persons listed above. Please list name, relationship, and telephone number
In the event that I, or my child(ren) should become ill or injured, I authorize emergency medical care, treatment by a physician and/or a medical treatment facility. I hereby release, absolve, indemnify and hold harmless the Conanicut Island Sailing Foundation, its staff, and Board Members from any liability resulting from my and /or my child(ren)’s participation in CISF sponsored activities and/or programs, including, but not limited to my and my child(ren)’s arrival, departure and/or transportation to and from the activity.
Signature *

Clear
Date *

Month Day Year
Date
Swimming
Anyone participating in a CISF program where sailing is involved (free public sailing included) must be able to swim.

I hereby certify that the program participant(s) can swim and are comfortable in the water.
Signature

Clear
Date

Month Day Year
Date
Should be Empty: