Parental/guardian Permission And Medical Release printable pdf download

Tour Code ____________________

Booking # ______________

PERMISSION AND MEDICAL RELEASE FORM

MINOR NOT ACCOMPANIED BY PARENT

“Minor” as used herein is ________________________________________Age:______

(Print participant name)

“Responsible Adult” as used herein is ________________________________________

(Print name of accompanying adult)

“OARS” as used herein, is O.A.R.S. Canyonlands, Inc., its officers, agents, employees

and stockholders and all other associated persons or entities.

“Medical Professional” as used herein is any licensed physician, nurse or emergency

medical technician.

I give my permission for Minor to accompany Responsible Adult on an activity outfitted

and guided by OARS. OARS may rely on Responsible Adult’s decisions for all purposes

regarding Minor, as if such decisions were made by me. I have signed a separate release

and indemnity with regard to Minor’s participation and I reaffirm said release and

indemnity, in general and specifically with regard to OARS’ reliance on Responsible

Adult’s decisions. Unless the signature of a “Second Parent or Guardian” is attached

below, I represent and guarantee that no second parent or guardian with legal

responsibility for Minor exists.

If OARS or Responsible Adult determines it is necessary, I authorize treatment of Minor

for sickness or injury by a Medical Professional. I authorize such use of hospital or

treatment facilities as is deemed necessary by a Medical Professional. I release and

indemnify OARS, any Medical Professional and all persons connected with and

providing care for Minor during the outfitted activity.

Signature of Parent or Guardian: ___________________________________________________

Printed name of Parent or Guardian: ________________________________________________

Address: ______________________________________________________________________

Date: ________________ Home Phone: _________________ Work Phone: _________________

Signature of Second Parent or Guardian: _____________________________________________

Printed Name of Second Parent or Guardian: __________________________________________

Address (if different): ____________________________________________________________

Family Doctor: ____________________________ Doctor’s Office Phone: __________________

Medical Insurance Company _______________________________ ID#____________________

1/28/08 KF Final

Parental/guardian Permission And Medical Release