JULIE BURGESS
Form IV Crew/ Passenger Medical Declaration
MANDATORY FOR CLASS 2 VOYAGES
This form is to provide medical information that might be needed in case of emergency.
All information is confidential and recorded through the Secretary Julie Burgess Inc. The information
is also kept by the Master of the Vessel on the sailing in a sealed envelope and only opened in an
emergency.
Sailing Details:
*
Dates from:
*
Dates to:
*
PERSONAL DETAILS
Name:
*
First Name
Last Name
Crew Classification:
Age:
*
Home Address:
*
EMERGENCY CONTACT 1
Name:
*
First Name
Last Name
Relationship:
*
Phone:
*
Format: (000) 000-0000.
EMERGENCY CONTACT 2
Name:
*
First Name
Last Name
Relationship:
*
Phone:
*
Format: (000) 000-0000.
DOCTORS DETAILS
Name:
*
First Name
Last Name
Phone:
*
Format: (000) 000-0000.
Address:
*
Please notify the Master of the Vessel on the sailing of the location and nature of any medications that may be
required in an emergency. ie nebulisers: nitro-glycerine (or other heart medications) Insulin, adrenaline etc..
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JULIE BURGESS
Form IV Crew/ Passenger Medical Declaration
MANDATORY FOR CLASS 2 VOYAGES
Please tick if you suffer from any of the following:
CONDITIONS
*
Epilepsy
Diabetes
Heart Condition
Glucose Intolerance
Asthma
Travel Sickness
ALLERGIES
*
Penicillin
Any Food ie. Nuts
Other Drugs
Bites/Stings
Dizzy Spells/Fits
Other allergies or medical conditions not specified above.
Any medication, special care or diet restrictions that we should know about in general or in the case of an emergency.
Any other relevant information that may be needed in the case of an emergency: (Medication taken, allergies to drugs, religious restrictions etc).
CONSENT:
In the event of an accident or illness when it is impractical or impossible to communicate clearly with me. I understand that the Master of the vessel will make arrangements for such medical treatment as may be deemed necessary.
Signature:
*
Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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