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Stonehaven 2022 Registration
Stonehaven 2022 Registration
Colin Burgess, Sailing Coordinator
2021-07-15T14:11:05+10:00
Stonehaven Participant Registration and medical form 2022
Participant Name
*
Participant Name
First
First
Last
Last
Participant Email
*
Participant Club
*
Participants Phone
*
Participants Australian Sailing Number
*
Participants D.O.B
Have you passed a swimming assessment
*
Yes
No
Do you have approved safety gear(incl buoyancy vest & protective clothing)
*
Yes
No
By entering I agree to the below
Participant Signature
*
signature
keyboard
Clear
Parent/Guardian
*
Parent/Guardian
First
First
Last
Last
Parent Phone - Business hours
*
Parent Phone - After hours
*
Parents Email
*
Stonehaven Indemnity Form
We have read the Stonehaven Indemnity form
*
yes
Confidential medical Information (This information is intended to assist in case of a medical issue or emergency. All participants are to complete this form as a pre-requisite for entering the Stonehaven Cup Regatta.)
Contacts details of family Doctor
*
Medicare Number
*
Medical Fund
Medical Fund Number
Text
Does participant suffer from any of the following
*
Asthma
Fits
Heart Condition
Blackouts
Motion Sickness
Migraine
Other
Other
None
Allergies to
*
Penicillin
Other Drugs - Specify
Other Drugs - Specify
Foods - Specify
Foods - Specify
None
What Special care is recommended
Dietary requirements
Year of last tetanus immunisation
Are you full COVID Vaccinated
*
Yes
No
Is participant taking tablets and/or medicine
*
No
Yes - State medication name, dosage etc
Yes - State medication name, dosage etc
Medical Attention
Signature Of Participant
*
signature
keyboard
Clear
Signature of Parent/Guardian
signature
keyboard
Clear
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If you are human, leave this field blank.
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