2025 Robie Pierce One Design Regattas Medical Form

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* 1. What is your first name?

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* 2.
What is your last name?

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* 3. What is your disability?

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* 4. In which of the Robie Pierce Regattas will you compete?

Robie Pierce One-Design Regatta Only

Robie Pierce Women's Invitational Regatta Only

Both the Robie Pierce Women's Invitational and the Robie Pierce One-Design Regatta

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* 5. What is your blood type?

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* 6. Do you have any chronic ailments? Please check all that apply?

Asthma, or other respiratory problems

Diabetes or hypoglycemia

Hemophilia or other bleeding problems

Circulatory or heart problems

Epilepsy / seizure

I do not wish to answer

Other (please specify)

None of the above

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* 7. Do you have any allergies? Please check all that apply.

Medication - please list below

Bee stings / insect bites

Do you carry an Epipen?

Latex

I do not wish to answer.

None of the above

Medications or Other (please specify)

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* 8. Date of last Tetanus/Diptheria/Toxoid Shot?

Date

I do not know

I do not wish to answer.

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* 9. Have you received the Hepatitis Immunization?

Yes

I do not know

I do not wish to answer

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* 10. Name and dose of current medications.

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

Name:

Phone Number:

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* 12. Who is your emergency contact?

Name:

Relationship:

Phone Number:

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* 13. 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 undersigned cannot be reached:

I agree

I disagree

I do not wish to answer

We look forward to you attending the Robie!

2025 Robie Pierce One Design Regattas Medical Form

Question Title

* 1. What is your first name?

Question Title

* 2. What is your last name?

Question Title

* 3. What is your disability?

Question Title

* 4. In which of the Robie Pierce Regattas will you compete?

Question Title

* 5. What is your blood type?

Question Title

* 6. Do you have any chronic ailments? Please check all that apply?

Question Title

* 7. Do you have any allergies? Please check all that apply.

Question Title

* 8. Date of last Tetanus/Diptheria/Toxoid Shot?

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* 9. Have you received the Hepatitis Immunization?

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* 10. Name and dose of current medications.

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

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* 12. Who is your emergency contact?

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* 2.
What is your last name?