MEDICAL DECLARATION

(A) Do you suffer from any medical condition that require regular treatment including medication? (This includes respiratory conditions such as asthma; or allergies.) YES / NO If yes, please specify: *

(B) Are you allergic to any medication (such as acetaminophen, aspirin.) YES / NO If yes, please specify: *

(C) Do you suffer from any physical or psychological conditions which our instructors should be aware of? YES / NO If yes, please specify: *

Can you swim? *

• YES
• NO

If you are unable to swim, you must be confident and comfortable in the water. If this is not the case then you may not enroll on any power boat activities run by CCR motor cruiser training Do you have any special dietary needs? If yes, please specify: *

Full Name *

Relationship *

Address *

Tel. No. (Daytime) *

Mobile, Tel. No. *

Submit