Exit this survey

Medical Information

Question Title

Image
Emergency Medical Information and  Waivers for the Robie Pierce One-Design Regattas:

The following Emergency Medical Information and Waivers will be transcribed to a form for your signature at registration. 

Remember to complete the guest form at the end of the medical questions.  Thank you!

Question Title

* 1. Please provide the following information:

Question Title

* 2. Mobile phone number:

Question Title

* 3. Disability:

Question Title

* 4. Click all that apply. A minimum of one must be checked to quailfy for entry.

Question Title

* 5. Chronic ailments: (Check all that apply)

Question Title

* 6. Allergies: (Check all that apply)

Question Title

* 7. Date of last Tetanus/Diphtheria/Toxoid Shot (Best guess if you are unsure)

Date
Date
Date

Question Title

* 8. Blood type:

Question Title

* 9. Have you received the Hepatitis immunization?

Question Title

* 10. Current medications if any: (Name/Dose/Frequency)

Question Title

* 11. Physician who conducted your most recent physical examination:

Question Title

* 12. Emergency Medical Contact:

Question Title

* 13. Please indicate if you have any dietary restrictions.

Question Title

* 14. EMERGENCY MEDICAL CONSENT

I, the undersigned, do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis or procedure rendered under the general or specific supervision of any member of the medical staff or of a dentist licensed under the provisions of the Stated Education Law and/or Public Health Law of the State and on the staff of any hospital holding a current operating certificate issued by the State Department of Health.  It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power to render care which the aforementioned physician in the exercise of his best judgment may deem advisable.  It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the individual that I have designated on this form as my Emergency Medical Contact cannot be reached.

Question Title

* 15. PARTICIPANT WAIVER

I, ACKNOWLEDGE, AGREE AND REPRESENT that I understand the nature of the sport of sailing and sailboat racing, both on the water and any land-based activities connected with such activities (separately and together, the “Regatta), and that I have had an opportunity to evaluate myself the present and future weather and sea conditions and the adequacy of the vessel, including safety equipment and rigging, in which I will be participating in the Regatta for such conditions, and that I am responsible for the safe operation and condition of the vessel, and for deciding whether and/or when to wear life jackets or other personal safety equipment.

I FULLY UNDERSTAND AND ACCEPT that:  the Regatta involves risk and dangers of serious bodily injury and death by drowning or otherwise; property damage and other economic loss (separately and together, “risks”); such risks and dangers may be caused by my own actions or inactions, the actions or inactions of others participating in the Regatta, including third parties who may attempt to assist me or others, the conditions in which the Regatta takes place, or the negligence of myself or any others, including those released herein; there may be other risks and losses either not known to me or not readily forseeable at this time; and I KNOWINGLY AND FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR INJURY, DAMAGE, LOSSES and COSTS of all kinds that I incur as a result of my participation in the Regatta.

I FURTHER FULLY UNDERSTAND AND ACCEPT THAT the American Yacht Club and Larchmont Yacht Club (separately and together, the “Host Clubs”) are not responsible and will not accept any liability for bodily injury, death or property damage suffered from any cause.  I participate in the Regatta entirely at my own risk, and I agree that I shall be responsible for all actions of my crew or guests.  In the event of a breach of conduct, sportsmanship, destruction of property, or failure to comply with the request of any race officer, committee member or agent of the Host Clubs, I will be held responsible and I shall be subject to protest and disqualification.

I HEREBY FOREVER RELEASE, DISCHARGE AND COVENANT NOT TO SUE each and all of the Host Clubs, the organizing authority, their administrators, trustees, officers, employees, contractors, members, volunteers, or agents of any kind, other participating regatta organizers, sponsors, or advertisers, on or under whose authority the Regatta takes place (each a Releasee), from and WAIVE any and all present or future claims, demands, rights of action or causes of action, judgments, losses or damages, caused or alleged to be caused in whole or in part by the actions or inactions of the Releasees, whether negligent or not; that I may have, or claim to have, against any, each and all of the Releasees, as a result of participating in the Regatta.

I agree to be bound by all the rules that govern this event.  I will inform all crew members of the conditions stated herein for their participation in the Regatta.

Question Title

* 16.
Thank you for providing this information. If you have an additional questions about the medical information provided, please call Siobhan Reilly at (914) 329-2761 or e-mail her at reillyhere@optonline.net. For questions on boat adaptations, call Buttons Padin at (914) 834-5476 or e-mail him at EPadin@padesta.com.

Here's to another great Robie Pierce One-Design Regatta.

T