The following document was used by the CSUN Surf Club for all members joining the club and/or the surf team. This document was acceptable to the university for club purposes but was not reviewed by a lawyer. It should be kept by the coach and be available at all events that the club/team participates in.

CSUN SURF CLUB INSURANCE INFORMATION SHEET

NAME_____________________________________________________________

ADRESS___________________________________________

_______________________________________

_______________________________________

TELEPHONE_______________________________________ AGE (As of 1/1/YY)__________________

BIRTHDATE_______/______/______

PLEASE CHECK YOUR CURRENT PERSONAL INJURY MEDICAL INSURANCE STATUS.

______I am insured under my parent's medical insurance policy.

• Parent's Name_____________________________________

  Parent's Telephone_________________________________

  Insurance Company_________________________________

  Insurance Policy #___________________________________

  In case of emergency please contact: ____________________________________ Telephone:________________________________

______I am insured under my own medical insurance policy.

• Insurance Company_________________________________

  Insurance Policy #__________________________________

  In case of emergency please contact: _____________________________________ Telephone:_______________________________

______I do not presently have any personal injury insurance. (Get these signed up under some club coverage ASAP!)

• In case of emergency please contact: ____________________________________ Telephone:________________________________

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Maintained by da hulk.

Last modified on 1/28/98.