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STATEMENT OF MEDICAL OR HEALTH ISSUES, PERMISSION TO TREAT AND ASSUMPTION OF FINANCIAL RESPONSIBILITY FOR TREATMENT
My name is __________________________________________
The safety of our participants is our first priority.  Personnel associated with Camano Power and Sail will use only First Aid, CPR or, in the case of heart problems, automatic electronic defibrillation on any participants in any of its programs.  Exceptions are the application of a device or medicine or treatment that the participant themself carries and uses, provided that the Camano Sail and Power personnel applying the device, medicine or treatment have previously been given instructions in the correct application, and providing that, in the case of a participant under the age of 18, a MEDICAL TREATMENT AUTHORIZATION FORM SIGNED BY A PHYSICIAN is on file with Camano Sail and Power.  If a medical or health issue beyond the ability of these basic procedures arises, or if Camano Sail and Power personnel are not able to, or are hesitant to apply the participant-owned treatment for any reason, 911 will be used to summon more advanced, emergency care.  In the case of outside medical intervention of any kind, I , or in the case of a participant under the age of 18, their parent or guardian, will assume full financial responsibility for any expenses  associated with such  intervention on  the participant's behalf.
In order to provide Camano Sail and Power with the information that we need to keep you as safe as possible, we need to know about any health or medical issues that may impact your wellbeing while a participant in our sailing classes.  Keep in mind that such issues could arise due to exposure to sun, very cold water, contact with living things in the water, such as stinging jellyfish, or on land, such as stinging insects.

Are you currently taking medication or using a treatment that may have to be  administered by someone else ?   No_____   Yes_____ and the details of the medication and its application are as follows:     __________________________________________________________________________________________________
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Do you have asthma?  No_____  Yes_____   If yes, do you carry an inhaler?  Yes______  No______   What is the usual trigger or cause of your asthma attack?   ____________________________________________________________________________________________
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Are you diabetic?  No____  Yes____   If yes, do you carry insulin?  No____  Yes____  If yes, what is the frequency of the dosage and the type of insulin?_________________________________________________________________.
Do you carry the treatment with you?  Yes____  No_____
 Are you allergic to anything that can cause you to have a serious allergic reaction?  No____  Yes____ If yes, do you carry an emergency medical treatment Yes_____  No_____   Type of treatment______________________________________
Can sunscreen be applied to you?  Yes____  No_______
Are there any limiting factors that may influence  the activities that you can engage in?  Examples could be an injury, a prosthetic device, a deficiency in one of the senses, for example hard of hearing or must wear glasses while sailing.  _______________________________________________________________________________________________
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Swimming ability/water comfort:  Concerning my swimming ability and comfort level in the waters of Puget Sound, I'd say that I am a very good swimmer____, moderately good swimmer____, poor swimmer____ , non-swimmer______.
In terms of me being in the waters of Puget Sound, it does not bother me at all___, it bothers me a little bit___, it bothers me a lot and I really don't want to be in the waters of Puget Sound____.

Any other medical or health concerns that you feel we should know about?  No_____  Yes______  List or explain here______________________________________________________________________________________________
__________________________________________________________________________________________________ __________________________________________________________________________________________________                                                                                                                                                                           
____________________________        _____________________________                  ___________________
Printed name of participant                          signature of participant                                                Date
_____________________________        ______________________________                ___________________
Printed name of parent or guardian               signature of parent or guardian                                 Date    
for participant under 18 years old.                                       


First emergency phone number_____________________  Name of person_________________________
Relationship__________________

Second emergency phone number___________________ Name of Person_________________________ Relationship__________________