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 NameLast Name
Year Born
Parent or Guardian Name

First NameLast Name
Parent or Guardian Name

First NameLast Name
PRIMARY Phone Number

Area CodePhone Number
CELLULAR

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
EMERGENCY CONTACT

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
PROGRAM OR CLUB Affiliation
NAME OF PHYSICIAN

First NameLast Name
PHYSICIAN Phone Number

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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Narragansett Bay Yachting Association