Buckles and Boards Ski Shop, Inc.
SKI/SNOWBOARD WEEKEND
Medical Release & Release of Liability
Email Order Number
Name: _____________________________________ Birth Date: ___________
CHILDREN('S) Name(s) (if applicable): _______________________ Birth Date(s): ___________
CHILDREN('S) Name(s) (if applicable): _______________________ Birth Date(s): ___________
Mailing Address _________________________________________________
_________________________________________________
Email Address
I the parent/guardian of the above named child(ren) have been made aware Buckles and Boards Ski Shop, Inc. is not covered by insurance for persons injured while taking part in any program, activity, or trip. In consideration of my and or my child(ren’s) upcoming participation I hereby hold Buckles and Boards Ski Shop, Inc. its servants, and employees harmless from any injury my child or I may incur while taking part in this trip. Further, I am delegating authority in advance of any specific diagnosis to the doctor/clinic/hospital to exercise their best judgment as to necessary medical/surgical treatment for my child in the event I cannot be reached. I agree to hold harmless Buckles & Boards Ski Shop, Inc. its servants, employees and any doctor/clinic/hospital treating my child for failure to obtain my consent.
Signature (Parent / Guardian):______________________________
Printed Name (Parent / Guardian): __________________________________
Email Address:
Email Address:
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Medical Insurance Co: _______________________________________
Policy Number: _______________________________________
Allergies and Medications: (If
any explain)________________________________________
____________________________________________________________________________
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