Medical Release & Release of Liability

 

CHILD #1 Name: _____________________________________          Birth Date: ___________

 

CHILD #2 Name: _____________________________________          Birth Date: ___________

 

Mailing 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. 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 program. 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.

 

Print name of parent/ Guardian:             _______________________________________

Signature of Parent/Guardian:            ______________________________________

Email Order Number (from receipt provided by on line checkout) ____________________________

 

Mothers work Phone:             _______________________________________

Father’s Work Phone:              _______________________________________

 

Medical Insurance Co:             _______________________________________

Policy Number:                                 _______________________________________

 

Child’s Allergies (If any explain)            ______________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

 

Use the print button (or file / print) of your browser to print a copy of this document for signature.

This form may be faxed to (781) 834-0311, or mailed to: Buckles and Boards Ski Shop, Inc., 2148 Ocean St., Marshfield, MA 02050

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