- Parental Authorization & Consent Form...
As the parent/legal guardian of said minor, I do hereby authorize an adult representative of the _______________________________(name of school) to sign any medical release or make any decisions recommended by a physician attending said minor in the event of an accident. In addition, I authorize members of the ski areas medical staff to administer first aid to said minor in the event of an accident occurring on the slopes. I understand the risks inherent in the sport of skiing and agree to be responsible for payment of all expenses incurred. It is understood that this consent is given in advance of any accident or illness that requires diagnosis and treatment and is given to authorize physicians to use their best judgment and to proceed immediately with necessary treatment.
I give permission for _____________________ to attend the ski trip to Whistler / Blackcomb Resorts, British Columbia, Canada on:
| Date: | _______________ | Sex | _______________ |
| Students Name: | _______________ | Grade: | _______________ |
| Address: | ___________________________________________________ | ||
| D.O.B: | _______________ | ||
| Name of Parent / Guardian: | _______________ | Day / Office Tel: | _______________ |
| Other phone / Location where parents may be reached during the trip: | _______________________________ | ||
Emergency contact for trip dates:
| 1. Name & Phone: | _____________________________________________________ |
| 2. Name & Phone: | _____________________________________________________ |
| 3. Name & Phone: | _____________________________________________________ |
Please make sure that the emergency contacts will know location of parents during the trip.
| Name of Insurance company that covers student (Include personal Health Number): |
| _______________________________________________________________ |
| Physicians Name & Phone #: |
| _______________________________________________________________ |
| Please list any recent operation, accidents, illness: |
| _______________________________________________________________ |
| Please list any allergies: |
| _______________________________________________________________ |
| Please list any medications: |
| _______________________________________________________________ |
| Credit Card Number to pay for medical services: Visa / Mastercard / Other (Please circle) | |||
| Card # | _____________________ | Exp. Date: | ________________ |
| Signature of parent / Guardian: | _____________________ | Date: | ________________ |
