PARENT
CONSENT, WAIVER OF LIABILITY
AND MEDICAL
RELEASE
INTERSCHOLASTIC SAILING ASSOCIATION (ISSA),
PACIFIC COAST INTERSCHOLASTIC SAILING ASSOCIATION (PCISA),
AND THE SAN DIEGO YACHT CLUB
2002 BAKER ELIMINATION REGATTA
Student’s Name: __________________________________________________________
Date of Birth: _____________________ School: _____________________________
List
all known allergies to medications:
_____________________________________________________
Date
of last tetanus shot: ___________________ Current
medications: _________________________
Medical Insurance
Information:
Father’s Insurance Coverage Mother’s Insurance Coverage:
Carrier: _____________________________________ Carrier: _______________________________________
Policy
#: ___________ Group #:
________________ Policy #:
_____________ Group #:
__________________
As
the parent/guardian of the above named student, I hereby acknowledge that the
risk of injury, including serious debilitating injury, is involved in athletic
participation. I recognize that ISSA,
PCISA, and The San Diego Yacht Club and their representatives make efforts to
reduce these risks, but further recognize that their efforts cannot and will
not eliminate all such risks. I am
aware of the risks involved, and give my consent for the above named student to
participate in all activities associated with the Baker elimination regatta.
I am
aware that ISSA, PCISA, and The San Diego Yacht Club do not carry medical
insurance for students and that medical insurance coverage will be provided by
parent/guardian. Evidence of such
coverage is provided above.
I
further release and hold harmless ISSA, PCISA,
The San Diego Yacht Club, their Officers, Directors, Trustees, agents,
employees, coaches and athletic trainers from any and all liability arising
from the above-named student’s participation in the Baker elimination regatta
and all related activities.
PERMISSION FOR
MEDICAL CARE
I hereby grant permission to
any appropriately qualified health care professional to give any and all
medically appropriate emergency care to my son/daughter/ward, including but not
limited to anesthesia and surgery.
____________________________________________ ___________________________________________
Father/Legal Guardian Date
Mother/Legal Guardian Date
____________________________________________
___________________________________________
Address Address
____________________________________________
___________________________________________
City State Zip City State Zip
____________________________________________
___________________________________________
Home telephone Work telephone Home telephone Work telephone
2002 BAKER
ELIMINATION REGATTA
April 27-28, 2002
School: __________________________________________
Team Contact: ______________________________________
Day Phone: ______________________Evening Phone: _________________________
Address: _________________________________________________________
City: ________________________ State: _____ Zip: ________
Team Information:
Sailor Name: Year
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Entry Fees: $25.00 per team $___________
Please make checks payable to: Sherri Campbell
Team Captain Signature: ______________________________ Date: _____________
Return by April 24, 2002 to:
Sherri Campbell
1580 Santa Barbara Street
San Diego, CA 92107
Fax 619-222-0538 between 9 AM and 9 PM