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*
    First Name*
    Middle Name
    Last Name*
    Suffix
    Phone*

    Emergency Contact(s)  (Step 3 of 6)

    -- 1st Contact --
    Full Name*
    Relationship*
    Phone*
    Text Msg

    -- 2nd Contact --
    Name
    Relationship
    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

    Medical Details

    Notes

    Insurance  (Step 6 of 6)

    Insurance Carrier
    Insurance Group
    Insurance Id

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