CSYC Junior Sailing

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Junior Member   (Step 1 of 6)

First Name*
Last Name*
Nic Name
Photo Release Approved YesNo
Date of last TDAP
CSYC Parent

Physician Information  (Step 2 of 6)

Prefix* —Please choose an option—DrPAMrMrsMs
First Name*
Middle Name
Last Name*
Suffix
Phone*

Emergency Contact(s)  (Step 3 of 6)

-- 1st Contact --
Full Name*
Relationship* —Please choose an option—FatherMotherBrotherSisterUncleAuntGuardian
Phone*
Text Msg

-- 2nd Contact --
Name
Relationship —Please choose an option—FatherMotherBrotherSisterUncleAuntGuardian
Phone Phone
Text Msg

Aliments & Allergies  (Step 4 of 6)

Click all Ailments that apply...
Asthma       YesNo
Hemophilia    YesNo
Diabetes        YesNo
Circulatory     YesNo
Epilepsy/Seizure   YesNo

Click all Allergies that apply...
Food Allergy          YesNo
Medication Allergy YesNo
Bee/Insect Allergy  YesNo
Latex Allergy     YesNo

Medicines  (Step 5 of 6)

Current Medicines
N/A

Medical Details
N/A

Notes
N/A

Insurance  (Step 6 of 6)

Insurance Carrier
Insurance Group
Insurance Id