2022 Summer Lessons Emergency Contact Form Page – Taylor Pond Yacht Club

2022 Family Emergency Contact Form

The emergency family contact and vital information form is REQUIRED for all students (children and adults) participating in Summer Lessons at Taylor Pond Yacht Club in 2022. The form is suitable for up to three students per family, those with more than three students require a secondary form to be completed. For your convenience, this form can be partially completed and "saved & completed later" using the save button at the bottom of the form.

Family Name

Last Name

Family Address

Street Address City State ZIP Code

Parent/Guardian #1 Contact Information

Parent/Guardian #1 Name

First Last

Parent/Guardian #1 Cell Phone

Is it OK to text the parent/guardian #1?

Yes

Parent/Guardian #1 Home Phone

Parent/Guardian #2 Contact Information

Parent/Guardian #2 Name

First Last

Parent/Guardian #2 Cell Phone

Is it OK to text the parent/guardian #2?

Yes

Parent/Guardian #2 Home Phone

Additional Emergency Contact Information

Additional Emergency Contact Name

First Last

Relationship to Family

Additional Emergency Contact Cell Phone

Texting the Emergency Contact

Is it OK to text the emergency contact about the students in this family?

Yes

Additional Emergency Contact Home Phone

Transport by the Emergency Contact

Does the emergency contact have permission to transport the students in this family?

Yes

Family Medical/Doctor Information

Preferred Hospital

Medical Practice Name

Medical Practice Phone

Primary Care Physician

Insurance Company

Insurance Group Number

Student 1 - Vital Information

Student 1 - Name

Student 1 - First Name Student 1 - Last Name

Student 1 - 2022 Lessons

Sailing

Swim

Tennis

Student 1 - Relationship to Parent

Student 1 - Age

Student 1 - Date of Birth

Student 1 - Known Allergies

Student 1 - Current Medications & Dosage

Student 1 - Travel Permissions

Does the student have permission to arrive/depart unaccompanied by an adult? (drive/bike/walk/boat)

Student 1 - Physical Limitations

Should there be a limit on physical activities for this student?

Student 2- Vital Information

Student 2

Student 2 First Name Student 2 Last Name

Student 2 - 2022 Lessons

Sail

Swim

Tennis

Student 2 - Relationship to Parent

Student 2 - Age

Student 2 - Date of Birth

Student 2 - Known Allergies

Student 2 - Current Medications & Dosage

Student 2 - Travel Permissions

Does the student have permission to arrive/depart unaccompanied by an adult? (drive/bike/walk/boat)

Student 2 - Activity Limitations

Should there be a limit on physical activities for this student?

Student 3 - Vital Information

Student 3 - Name

First Last

Student 3 - 2022 Lessons

Sailing

Swimming

Tennis

Student 2 - Relationship to Parent

Student 3 - Age

Student 3 - Date of Birth

Student 3 - Known Allergies

Student 3 - Current Medications & Dosage

Student 3 - Travel Permissions

Does the student have permission to arrive/depart unaccompanied by an adult? (drive/bike/walk/boat)

Student 3 - Activity Limitations

Should there be a limit on physical activities for this student?

Additional Notes

Please share with us any additional information we may need to know about the health and well being of your family members.

Parental Consent Section

Medical Release(Required)

I, the parent of the above, named child, do hereby release, absolve, indemnify and hold harmless the Taylor Pond Yacht Club, the instructors and volunteers, any and all of them in case of injury to my child.

I agree to the medical release

Consent to Medical Treatment(Required)

I, the parent/guardian of the above, named students authorize Taylor Pond Yacht Club to obtain emergency medical treatment for my child in the case of sudden illness or accident.

I consent to this medical treatment policy