HTML Preview Generic Medical Consent Form page number 1.
Medical Consent Form
Only completely filled in forms will be accepted. Doublehanded skippers and crews must EACH
complete and sign separate copies of this form. Please attach a copy of your health insurance card.
NAME OF PARTICIPANT (printed):_________________________________________________
NAME OF PARENT OR GUARDIAN (printed): ________________________________________
In the event of accident or injury to myself, my spouse or any child of mine (specifically including my
child named above as "Participant") or in the event of illness of myself, my spouse or any child of
mine while on or about the premises of the Host Club/Organization while participating in an event
under the auspices of the Host where I am unable to consent or am not present:
1. I hereby voluntarily consent to the furnishing to myself, my spouse or any child of mine of such
medical care and treatment by any hospital or physician(s) as the hospital or physician(s) deem
necessary or advisable.
2. I authorize any officer or member of the Host to consent to such medical care or treatment.
3. I agree to pay the reasonable cost of such medical care or treatment and to indemnify and hold
free and harmless of all liability for such cost the Host and US SAILING and its officers and
members.
I hereby authorize any x-ray examination, anesthetic, medical or surgical diagnosis or procedure
supervised by any member of the medical staff or of a dentist licensed under the State Education Law
and/or Public Health Law of the State and of the staff of any hospital holding a current operating certificate
issued by the State Department of Health. This authorization is given in advance of any specific
diagnosis, treatment or hospital care being required in order to provide authority to render care, which the
aforementioned physician in his best judgment may deem advisable. Effort shall be made to contact me
before rendering treatment to the patient, but any of the above treatment will not be withheld if I cannot be
reached.
Signature of Parent/Guardian:_________________________________ Date:
______________
IN CASE OF EMERGENCY CALL:
NAME RELATIONSHIP PHONE NUMBER
PHYSICIAN WHO CONDUCTED YOUR MOST RECENT PHYSICAL EXAMINATION:
NAME PHONE NUMBER DATE OF LAST EXAM
HEALTH INSURANCE CARRIER INSURANCE ID NUMBER
PLEASE FILL OUT THE REVERSE SIDE