Adult Medical Form

Please print, sign & bring with you to the course

First Name__________________________Surname_________________
Address____________________________Post Code____________

Emergency Contact ( Next of Kin )
Address____________________________Post Code____________
Phone ___________________Work_______________Mobile___________

The following information is requested so that in the event of an emergency appropriate action can be taken and particularly so that in the unlikely event of an emergency in which you are seriously incapacitated, appropriate information can be given to emergency services.

Do you have any allergies? e.g. elastoplast, penicillin, foods?
Do you have any medical conditions which require regular or symptomatic medication e.g. diabetes, asthma, angina?
Have you any medical conditions which should be notified to hospital casualty?
Are you taking regular medication which should be notified to hospital casualty?
Do you have any other relevant medical condition? e.g fits, blackouts, headaches?
Are you suffering from any injury?

If the answer to any of the above is YES please write details on the back of this form and discuss them with the Senior Instructor running the course. It is your responsibility to make known any medical condition that may affect your own personal safety during the activities associated with the course.

If medication may be required during training (including administered by others if you are incapacitated ) please give an explanation of what is required prior to the course starting. This will be given in confidence to the senior instructor running the course.

Name of GP________________________________Phone_____________

Declaration and Permission
I consider myself physically fit to take part in dinghy sailing and can swim 50 metres in light clothing with a buoyancy aid.
I give TSC Training Principal or their representative permission to contact the person above in the event of my being injured/taken ill. I give permission for the information provided on this form to be given to given to qualified first aiders / emergency services / hospital personnel on a “need to know” basis.

Queries Training Principal e mail phone 07740 879 049

Please see Insurance disclaimer overleaf

Insurance TSC is insured under the RYA Club Insurance Scheme including Sail Training Indemnity. TSC, TSC Volunteers, RYA Coaches, RYA Senior instructors or RYA Instructors do not accept responsibility for any loss, damage or injury suffered by persons and/or their property arising out of or during the course of their activities whilst training and/or coaching and/or instructing unless such injury loss or damage was caused by, or resulted from negligence or deliberate act.

Data Protection The personal information provided and detailed on this form will be held, used and deleted in accordance with Tynemouth sailing Club’s Data Protection Policy & Procedures