Medical Consent Form & Participant Waiver printable pdf download

MEDICAL CONSENT FORM & PARTICIPANT WAIVER

AUTHORIZATION BY PARENTS FOR ANOTHER TO CONSENT TO HOSPITALIZATION,

SURGURY, OR MEDICAL TREATMENT OF A MINOR CHILD

All blanks must be filled out. All blanks not applicable should be indicated N/A (not applicable)

This form must be competed, signed and turned into a Planet Hockey Staff Member at Check-in.

Students will not be allowed to begin Camp without completing this form.

More than one sibling may be listed.

Do not send or email this form.

Thank you, Planet Hockey, Inc.

NAME OF STUDENT(S):

__________________________

_________________

PLANET HOCKEY CAMP LOCATION:

CAMP DATES:

, 2016

Names of Parents or Legal Guardian (please print):

_________________________________________________________ __________________________________________________________

First

Last

Relationship

First

Last

Relationship

_________________________________________________________ __________________________________________________________

Address

Phone number

Address

Phone number

_________________________________________________________ __________________________________________________________

City

State

Zip

City

State

Zip

Names of Child and Medical Information (please print):

__________________________________________

________________________________________

___________________________

First

Last

Birthdate

________________________________________________________________________

Allergies/Medical Concerns

Medications

Health Insurance (please print):

_________________________________________

______________________________________________________________________________________________

Insurance Carrier

Policy Number

(Camp Dates)

During my (our) absence during Camp from _______________ to ________________ we appoint Planet Hockey personnel to consent (each individually) for all

medical or surgical treatment or other medical procedures to the child named above (including, but not limited to, emergency services, administration of anesthesia,

blood transfusions, diagnostic tests, etc.) that may be required during such absence.

Without in any manner limiting the foregoing appointment and authorization, if circumstances permit, we would like to have the following physician consulted in

connection with such medical or surgical treatment or medical procedures:

________________________________________________________________________

Name of Physician

Telephone Number

This appointment and authorization shall include and extend to all matters for which consent is required under the policies of any hospital or medical treatment

facility. In consideration of the services that are rendered to the child named above, pursuant hereto, I (we) agree to pay for all such services. This appointment and

authorization shall be effective until _____________, 20____ , unless sooner revoked by me (us).

Any hospital or medical facility, its officers and personnel, and any physician providing medical or surgical services to the child named above may rely upon the

consent given by the above-named appointee(s) (or either of them) with the same force and effect as if personally given by me (us).

Participant Waiver: Planet Hockey, Inc. will not assume responsibility for any injury incurred while participating in this Planet Hockey Skills Camp, both on the

ice and during off ice activities. Certain risks are inherent during the participation of a hockey camp and hockey training. Nor will Planet Hockey be liable for lost

or stolen items during the duration of camp. I, the undersigned for myself, my heirs and assigns, do hereby release Planet Hockey, Inc., employees, instructors,

counselors and agents from any and all claims for injury, death, loss or damage I may suffer as a result of my/my child’s participation in this Planet Hockey Skills

Training Program.

________________________________________________________________________

Signature of Parent or Legal Guardian

Date

________________________________________________________________________

Signature of Parent or Legal Guardian

Date