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:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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?
____________________________________________________________________________________________
__________________________________________________________________________________________________
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______________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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_____________________________
___________________
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__________________