Participant's First Name: *
Participant's Last Name: *
Participant's Age: *
Membership Number: *
Medical Waiver Form
Required information for each program participant.
NOTE: We only need one copy of the medical waiver for each child. If you have already submitted one for this particular child, you can skip the fields below.
Primary Care Physician:
Date of Birth:
Health Insurance Card Number:
Emergency Contact Name #1:
Contact #1 Phone Numbers:
Emergency Conctact Name #2:
Contact #2 Phone Numbers:
Do you have any allergies?:
If yes, please list all allergies:
Are any medications being taken?:
If yes, please list all medications:
Please list any medical conditions you feel we should be aware of:
Please list any restrictions on physical activities:
Scituate Harbor Yacht Club Acknowledgement of Rules and Regulations and COVID-19 Warning and Liability Waiver
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.
Scituate Harbor Yacht Club ('the Club') has put in place preventative measures to reduce the spread of COVID-19, however, the Club cannot guarantee that you or your child(ren) will not become infected with COVID-19 while at the Club. Furthermore, being present at the Club could increase your and your child(ren)'s risk of contracting COVID-19.
Please refer to the following questions before coming to programs or the Club property:
- Please screen your child daily for the following symptoms, and keep your child home if they or someone in your household has any of the following symptoms in the past twenty four (24) hours: cough, sore throat, difficulty breathing, gastrointestinal symptoms (diarrhea, nausea, vomiting), abdominal pain, unexplained rash, fatigue, headache, new loss of smell/taste, new muscle aches, or any sign of illness.
- Please do not come to the Club or any of the swimming, tennis or sailing programs ('Programs') on the property, if within the past fourteen (14) days, you, your child or anyone in your household has had close contact with a person known to be infected with Covid-19. Accordingly, you and your entire household shall not come to the Club or any of the Programs for fourteen (14) days, and you shall seek medical advice.
- In the event that you or anyone in your house is diagnosed with Covid-19, you shall notify the Club Manager immediately, and you or anyone in your household will not be allowed to return to the property until such time as you receive notice from a medical professional that you or anyone in your household are no longer positive for Covid-19, and no longer have symptoms.
By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by being present at the Club and that such exposure or infection may result in personal injury, illness, permanent disability, and/or death. I understand the risk of becoming exposed to, or infected by, COVID-19 at the Club may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Club employees, volunteers, and swimming, tennis or sailing program participants and their families.
I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself or my child(ren) (including, but not limited to, personal injury, disability, and/or death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)'s attendance at the Club or participation in Club's swimming, tennis or sailing programming ('Claims'). On my behalf, and on behalf of my child(ren), I hereby release, covenant not to sue, discharge, and hold harmless the Club, its employees, agents, members, volunteers, Executive Committee (collectively and individually) and representatives, of and from the Claims, including any and all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Club, its employees, agents, members, volunteers, Executive Committee (collectively and individually) and representatives, whether a COVID-19 infection occurs before, during, or after being present at or participating in any Club program, event, or activity.
I, as a Member of the Scituate Harbor Yacht Club, acknowledge that I have read the entire document on behalf of our family and those children who will be enrolled in swimming, tennis or sailing programs at the Club.
Parent's Name: *
Parent's Initials: *
(by initialing here you agree to the Acknowledgement and Waiver statement above)
||* indicates required information
First Name: (you must leave this field blank)
Last Name: (you must leave this field blank)