CONSENT FOR MEDICAL TREATMENT

Narragansett Bay Yachting Association
CONSENT FOR MEDICAL TREATMENT (Minor)

As the parent or legal guardian of the below listed child, I hereby give my consent for the medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve life, limb or well being of my dependent.
SAILOR FULL NAME *

First Name Last Name
Year Born *
Parent or Guardian Name *

First Name Last Name
Parent or Guardian Name

First Name Last Name
PRIMARY Phone Number *

Area Code Phone Number
CELLULAR

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
EMERGENCY CONTACT *

First Name Last Name
Emergency Contact Phone Number

Area Code Phone Number
PROGRAM OR CLUB Affiliation
NAME OF PHYSICIAN

First Name Last Name
PHYSICIAN Phone Number

Area Code Phone Number
Insurance Provider
Insurance Number
KNOWN ALERGIES
Any special medication or pertinent information
Signature
Enter the message as it's shown *
Date

Month Day Year
Date
Should be Empty:

Narragansett Bay Yachting Association