Medical Consent Form printable pdf download

Group Name: _________________________________ Reservation #: ____________________________

Group Leader: ________________________________ Arrival/Departure: _________________________

Authorization by parent(s) or guardian(s) for another to consent to hospitalization,

surgery or special medical procedures during absence of parent(s) or guardian(s)

(Please print or type all required information)

Name: _______________________________________________________________________________________

Date of Birth: ___________________________________ Soc. Sec. #: ___________________________________

Health History

Medical Problems: _____________________________________________________________________________

Rheumatic Fever __________ Diabetes __________ Epilepsy __________ Allergies ___________

Allergic to Drugs (i.e. penicillin, etc.) List: _________________________________________________________

_________________________________________________________________________

Allergic Reaction to Bee Stings: Yes _______ No ________ Unknown _______

Tetanus (Last injection): __________________________

Is Child under medical treatment now? Yes _________ No _________

Is Child taking medications? Yes ________ No _________ What Type? _________________________________

Child’s Physician: _______________________________________________ Phone: (

) __________________

Parent(s) or Guardian(s) Legally Responsible for Child

Name: _______________________________________ Name:________________________________________

Day Phone: (

) ______________________________

Day Phone: (

) _______________________________

Night Phone: (

) _____________________________

Night Phone: (

) ______________________________

We hereby appoint the appropriate staff of Snowshoe Mountain who, during my/our absence, shall be authorized to consent for

all medical and/or surgical treatment and/or special procedures (including, by way of illustration and not limitation, administra-

tion of anesthesia, blood transfusion, diagnostic tests, etc.) which may be required during our absence. Without in any manner

limiting the foregoing appointment and authorization. If circumstances permit, I/we would like to have our doctor consulted

in connection with such medical and/or surgical treatment and/or special procedures.

The undersigned agrees to pay all costs associated with such medical care and related transportation for the child and

indemnify and hold Snowshoe Resort Inc. and Snowshoe Resort Management Inc., its agents, employees and associates

harmless from any costs incurred therein.

________________________________________________

__________________________________________________

Signature

Date

Signature

Date

Please deliver to ski patrol office on your first day of skiing.

Medical Consent Form