World Dwarf Games Temporary Guardianship Form

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World Dwarf Games Temporary Guardianship Form
Temporary Guardian & Medical Release Form
Minors (under the age of 18 years old) attending the 2017 World Dwarf Games, August 4 to August 12,
2017 in Guelph, ON, Canada without their parents or normal legal guardian, must have a temporary
guardian designated for the week of the games. The parents of the unaccompanied minor who is
attending the 2017 World Dwarf Games must fill out the following form. This form MUST BE
NOTARIZED. The temporary guardian must be at least 21 years of age. This form must be included
with your registration form or your packet will be returned to you without processing. Please
complete the following information:
Minors Name: _
____________________Date of Birth _ _
_____
Health Plan Name: _
Health Plan Policy #: ________________
Group #: _
_________ I give my permission for my minor (name
___)
to receive full medical treatment in the event of an emergency.
Exceptions (if any): _ ___________
_________________________
I authorize (legal guardian name)
________________________________to be the legal guardian
for my minor during the week of August 4 to August 13, 2017 in Guelph, Ontario, Canada.
Signature of Parent _
Date
Fax (_______ _______) E-mail _
Name of Guardian (must be at least 21 years of age) _
Address _
_
City
________ Prov/State
__________Postal/Zip _
Signature of Guardian
Date _
Allergies of minor: _
Current listing of medications
_ Other medical needs or concerns:
____________ Physicians Phone Number: (___-_______ )
Notary Public Stamp/Signature__________________________________________
Date Commission Expires________________________
Please return this form with your Registration. The original can be handed in at check-in

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