CSYC Junior Sailing Your eMAIL 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
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