Ynhr Release

Pacific Skyline Council, BSA Sequoia Yacht Club Stanford University Sailing Center Release of Liability, Authorization to Treat Minor & Media Release

Your Name Here Regatta Name of Sailing Participant: _______________

Date of Birth: ______________

Release of Liability The Sea Scout Participant is voluntarily sailing in the Your Name Here Regatta. While safety is always our primary concern, any sporting event like sailing has risks of injury from operating a boat in a race. In the event of any injury, the Participant will hold harmless the Port of Redwood City, Stanford University, the Pacific Skyline Council, Sequoia Yacht Club and those volunteers running the Your Name Here Regatta. Authorization to Treat Minor The undersigned do hereby authorize (name of leader) ___________________, or such substitute as they designate as their agent for the Sea Scout, to consent to any x-ray examination, anesthetic, medical, or dental or surgical diagnosis or treatment and hospital care for the above minor which is deemed advisable by and to be rendered under the general or special supervision of any physician and surgeon, licensed under the Provision of Medicine Practice Act or of any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, Sea Scout event, or elsewhere. The undersigned understands that all or part of any medical expenses by above minor on any Boy Scout program or activity may be covered by said minor unit’s insurance policy. The authorization will remain in effect while the above minor is enroute to or from or involved in any Boy Scout activity, unless revoked in writing by the undersigned, and delivered to the aforesaid agent. Media Talent Release Photos and video will be taken during the Regatta for promotional materials that may appear in scouting publications, sailing press releases, social networking sites such as Facebook and websites promoting Sea Scouts. Date:___________

Parent/Guardian Signature:_________________________

Parent/Guardian Address:________________________________________ City:________________________ Home Phone:_________________ Cell Phone:___________________

Zip Code:_______________________ Business Phone:_____________

Primary Carrier & Policy Number: _____________________________________