2024 CYC Junior Activities Medical Release & Liability Waiver

CYC Junior Activities Medical Release & Liability Waiver

Summer 2024
All children enrolled in any CYC Junior Program MUST complete and submit the Medical Release/Liability form.

(Up to 4 children in the same family can be on the same form.)
Child's Name*

First NameLast Name
Child's Name

First NameLast Name
Child's Name

First NameLast Name
Child's Name

First NameLast Name
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email*
example@example.com
Parent/Guardian Cell Phone #*

Area CodePhone Number
Parent/Guardian home or work Phone #

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #1*

First NameLast Name
Phone Number*

Area CodePhone Number
Emergency Contact #2*

First NameLast Name
Phone Number*

Area CodePhone Number
Child's Physician Name*
Physician Phone Number*

Area CodePhone Number
Health Ins. Info, Policy & Group #*
My children will commute by:*

CarBicycleWalkOther
My child/children are participating in:*

Junior SailingFirst MatesJunior TennisStaff
Person(s) authorized to pick up my child(ren) other than those persons listed above. Please list Name, Relationship, and Telephone Number
Medical Information, Allergies, etc... that we should know about
In the event that 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 Yacht Club, its staff, trustees and members from any liability resulting from my child(ren)’s participation in Club sponsored activities, including, but not limited to my child(ren)’s arrival, departure and/or transportation to and from the Club.
Signature*
Date

MonthDayYear
Date
Should be Empty: