2016 – 2017 CENTER ICE SKATING CLUB
EMERGENCY MEDICAL RELEASE
I, ___________________________, of _____________________________________________am the
(Parent/Guardian of Minor) (Address)
_______________ of _________________, a minor, of_____________________________________
(Parent/ Guardian) (Child’s Name) (Address)
I hereby give my consent, in the event that all reasonable attempts to contact me at _______________
or _______________________________________at ________________have been unsuccessful, for:
(Other Parent/Guardian/Emergency Contact) (Phone)
1) The administration of any treatment deemed necessary by Dr. ____________________,
____________ or Dr_____________________, ______________ or in the event that the appropriate
(Phone) (Preferred Dentist) (Phone)
preferred practitioner is not available, by a licensed physician or dentist and
2) The transfer of the child to ______________________ or any hospital reasonably accessible.
The I and/or child is covered under the following Medical Insurance Company; ____________ and the Policy Number: __________________________
This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists concurring in the necessity of such surgery. The following is needed by any hospital or practitioner not having access to the adult’s/child’s medical history:
Allergies: ______________________ Medication being taken:______________________________
Date of last tetanus shot:______________
Physical impairments (Heart, epilepsy, etc.,): ___________________________________________
Other pertinent facts to which a physician should be alerted: ________________________________
I certify that I, an adult participant or the parent/guardian, of said participant, give my consent to the Center Ice Skating Club and the facility the activities are taking place in and their staff and to members of the Center Ice Skating Club, their Board of Directors and volunteers to obtain medical care from any licensed physician, hospital or clinic, including transportation and emergency medical services, for myself/ourselves and/or said participant for any injury that could arise from participation in these activities.
Parent/Guardian’s Signature: ___________________________ Date: ____________________
Adult Participant Signature: ____________________________ Date: ____________________
This consent for medical attention shall be binding and effective for the 2016-2017 membership year of the Center Ice Skating Club.