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OPA Racing ONLINE
2023
Membership Submission
All members will be required to sign their submitted membership paperwork in person
BOAT NAME / Team Name
*
BOAT NUMBER
*
MEMBERSHIP TYPE
Racing Member - Navigator
Non-Racing Member - Crew
Non-Racing Member - Industry
Position in Boat
FULL NAME
*
ADDRESS
*
EMAIL
*
Phone #
*
DATE OF BIRTH
*
Date of Last Tetanus Shot
Blood Type
Weight
CURRENT PRESCRIPTION MEDICATION(S)
*
CURRENT OVER THE COUNTER MEDICATION(S)
*
CURRENT SUPPLIMENT(S)/VITAMIN(S)
*
MEDICATION ALLERGIES? IF YES, PLEASE LIST
*
FOOD ALLERGIES? IF YES, PLEASE LIST
*
OTHER ALLERGIES
*
Doctor Name & Number
*
Insurance Company & Policy Number
*
MEDICAL HISTORY
*
HIstory of Seizures
Taking Steroids
Taking Blood Thinners
Diabetic
High Blood Pressure
History of Heart Issues
None Listed are Applicable
ADDITIONAL MEDICAL HISTORY
1st Emergency Contact (CANNOT BE THE PERSON IN THE BOAT WITH YOU)
*
2nd Emergency Contact
*
Credit Card #
Name on Card
Exp Date
CCV Code
Billing Zip Code
Please click on the checkbox to continue
*
Submit
Reset
MEMBERSHIP fees
Racing Member - $150.00
Non-Racing Member - $100.00
GO TO Registration Submission
