Form 3 MEDICAL TREATMENT PERMISSION
I…………………………………… being the Parent or Legal Guardian of………………………………………….…… (Print competitor’s name above and complete form below) hereby give my permission to my child’s coach or team leader (As specified in the form below) to sign for any medical or surgical treatment necessary for my child during the event as defined in the Notice of Race and Sailing Instructions for the RS:X Championship concerned.
| Last Name |
........................... | First Name(s) | ......................... | Sail # | ............................. |
| ISAF Sailor # | ............................. | ||||
| Address: | |||||
| Street: |
......................................................................... | City .......................................... | |||
| ......................................................................... | Zip .......................................... | ||||
| Country: | ........................... | ||||
| Mobile # | ........................... | Fax #........................................... | |||
| E-Mail: | ................................................. | Website:....................................... | |||
| Male: |
|||||
| Female: | Date of Birth.....................................(DD/MM/YY) | ||||
| APPOINTED TEAM LEADER OR COACH: | ................................................................................. | ||||
IMPORTANT MEDICAL HISTORY:
LAST TETANUS IMMUNIZATION DATE:
Current Medicines:
My child takes the following medicines (Specify):
Allergies:
My child has the following allergies(Specify):
International Medical Insurance:
My Child has insurance with this company(Specify):
Policy # Value:
This does allow....................(Please tick the relevant box) repatriation by special air taxi.
This does not allow............. (Please tick the relevant box) repatriation by special air taxi.
PERSON to contact in case of emergency if different from above
| Last Name |
|
First Name(s) | ................................................. | ||
| Address: | Zip | .................................... | |||
| Street |
.................................................................. | Country | .................................... | ||
| City | ................................... | ||||
| Mobile | ................................... | Fax : | ................................... | ||
| E-Mail : |
................................... | ||||
Present forms 1, 2 & 3 to REGISTRATION ON SITE
