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MBBC
JUNIOR SAILING PROGRAM --MEDICAL INFORMATION
Name________________________________________________________
Emergency
Contacts: Closest relation
first. Include parents
Name____________________________
Relation_____________________
Phone:
(O)_______________________ (H)____________________________
Name____________________________
Relation_______________________
Phone (O)
_______________________ (H)__________________________
Physician
________________________Telephone______________________
Insurance
Co. _______________________ Policy # _____________________
Birth Date
_______________Height ______________Weight ___________
Last tetanus
booster__________________ Contact lenses? Hard
Soft None
Allergies_______________________________________________________
Medications_____________________________________________________
Medical
concerns which affect your child’s ability to participate in the class
or that
would be pertinent to emergency medical treatment :
_____________________________________________________________
______________________________________________________________
______________________________________________________________
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