Derbyshire Youth Sailing

Host Club:____________ Date: ________ Paid (Y/N):______

EVENT ENTRY / CONSENT FORM

Sailor Details

Name:……………………………………………………………… Date of birth: ………………………….. Male/Female: ............

Address: ……………………………………………………………………………………………………………………………………………………………

Telephone: ………………………………………Mobile:……………………………………… email:-………………………………………………….

Boat Class: ……………………………Helm/Crew:……………… Sail No.:………………… Home Club: ………………………………

Adult(s) responsible for sailor named above during the event:………………………………………………………………………

Relationship to sailor of adult(s) responsible:…………………………………………………………………………………………………

Mobile no’s #1:…………………………………………………………….. #2:……………………………………………………………………………

Any other Emergency contact(s):………………………………………………………………………………………………………………………

If your sailor suffers from any of the medical conditions listed below, please circle and give brief details

Migraines Blackouts Epilepsy Fainting Diabetes Heart disease

Asthma Breathing difficulties Other ……………………………………………………………………

Is your sailor allergic to any medications or food products? (Y/N)

Details:

Is your sailor currently on any medication? (Y/N)…………..

Details:

Doctors name: ………………………………………………………………………………….. Telephone: …………………………………….

Address: ……………………………………………………………………………………………………………………………………………………………

Date of last Anti-tetanus injection: ………………………………………………………………………………………………

Swimming ability: Please indicate your sailor’s swimming ability (please tick):

N

Photography: A photographic record of the event maybe taken for display or promotional purposes, including use on the web site of Derbyshire Youth Sailing and/or our Facebook page.

If you object to this, please tell one of the organisers on the day.

Emergency Permission: In the event of an emergency I authorise qualified first aiders to administer medical care and, in case of emergency hospital treatment being required, I authorise the medical or dental treatment for the sailor named above.

Declaration: I declare that I am the adult responsible for the sailor named above and to the best of my knowledge, the above information is correct.

I consent to the sailor named above taking part in this event.

SIGNED………………………………………… Print Name……………………………………………………….

DATE …………………………………………….

Data Protection: The data on this form is for the sole use of Derbyshire Youth Sailing and the Organising Authority of the event. The data will not be passed to other third parties except for emergency purposes.