“GUESTS UNDER 18” WAIVER FORM
Parental Consent & Hold Harmless Agreement Dates: from _________to________
I/we give permission for _____________________________________, age________ to
participate in boating related activities with ___________________________________ ,
a member of Carefree Yacht and Boat Club on this date of _______________________.
_______________________________________________________/_______________
Signature of parent(s) / guardian(s) Date
In case of medical emergency, I/we understand that every effort will be made to contact the parent or guardian. In event I/we cannot be reached, I/we hereby authorize adults affiliated with the Carefree Yacht and Boat Club to act as agent(s) for me/us, to consent to any examination, x-ray, anesthetic, medical diagnosis or treatment which is deemed advisable by, and is rendered under the supervision of any physician or other qualified medical personnel.
Child’s Full Name: ________________________________________________________
Address: _______________________________________________________________
Phone Numbers: __________________________________________________________
Child’s Birth date: _____/_____/_________
Date of last Tetanus shot: _____/_____/________ Medications: ___________________
Known Allergies: _________________________________________________________
Other Health Conditions: ___________________________________________________
Insurance Company and Policy #: ____________________________________________
________________________________________________________________________
Signature of Parent(s) / Guardian(s)
In consideration for the agreement by Carefree Yacht and Boat Club to permit __________________________________(child’s name) to participate in boating related activities, I (we) agree to indemnify, protect and hold harmless the Carefree Yacht and Boat Club, its members, and affiliated personnel from any claim or liability whatsoever, including, but not limited to, personal injury and property damage, however caused, as a result of ________________________________________(child’s name) participating in these activities.
_________________________________________________________/______________
Signature of parent(s) / guardian(s) Date
