Medical Form

* = Required Field
Name*
First Last
Address*
Mailing Address City Province Postal Code
Preferred Phone*
Birth Date*
Date Format: MM slash DD slash YYYY
PHN (Health #)*
Dr. Name
Dr. Phone
Emergency Contact*
Emergency Phone*
Health conditions (includes allergies, medications and any diagnoses).*
Medications carried on you*
Swim Level*
Any current, formal medical training
Consent*
I hereby authorize the person/persons in charge to secure such medical advice and services deemed necessary for my health and safety. I will advise the Club of any changes in my medical condition.
Date*
Date Format: MM slash DD slash YYYY
CAPTCHA
This form will be brought on the boat during every practice and festivals.

2021Apr04 - Medical Form