Liability Release
LIABILITY RELEASE: (Sailors under the age of 18 must have a parent/guardian's signature.) I understand that skippers and crews sail entirely at their own risk, and that neither the CISA, ABYC, or other host clubs, their Directors or Officers, not the organizing bodies or committees or individuals appointed or volunteering for the CLINIC accept any liability for damage, material or personal, suffered during the CLINIC or at any other time.
Print Name: ___________________________________
Dated: __________ Applicant's Signature(s): ____________________________
Print Name: ___________________________________
If under 18, parent/guardian's signature: _________________________________
Student Medical Release
Participant's Name: __________________________________________
Participant's E-Mail Address: ___________________________________
Family Physician: ____________________________________________
Address: __________________________________________________
City, State: ________________________________________________
Tel: (___)______________
Zip: ______________
Insurance Co.: ______________
Policy Number: ______________
Have you been treated for:
| Rheumatic fever | Heart disease | Chronic disease of the lung |
| Asthma | Chronic ear disease | Disease of the bones of joints |
| Epilepsy | Other: _____________________________ | |
| Any vision or hearing defect | Do you wear contact lenses? | |
| Last Physical Examination: | ____________________________ | |
I, the undersigned, do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis rendered under the general or special supervision of any member of the medical staff licensed under the provisions of the Medical Practice Act or a dentist licensed under the provisions of the Dental Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital from the State of California Department of Public Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power to render care which the aforementioned physician in the exercise of his best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached.
Signed: ____________________________ Date: ______________________
(if over 21) Signature of Participant
(if under 21) Signature of Father, Mother or Guardian
In Case of Emergency, Please Notify:
Name: ____________________________ Tel: (___) ____________________
Name: ____________________________ Tel: (___) ____________________