2015 Release And Assumption Of Risks Agreement printable pdf download

2015 Release And Assumption Of Risks Agreement

2015 Sailing and Watersports Program

Release and Assumption of Risks Agreement

& Consent for Medical and Dental Treatment

Date: _____________________

General Information:

Participant’s Name: ___________________________

Gender:

o

Age: ______ Date of Birth: ___________

Male:

Telephone: _________________________

Female:

o

Address: ___________________________

Family Physician’s Name:

___________________________________

______________________________

___________________________________

Telephone: ___________________

If Under the Age of 18,

In Case of Emergency Contact:

Name of Parent and/or Guardian:

______________________________

___________________________________

Relationship: _________________

Telephone: _________________________

Telephone: ___________________

Address: ___________________________

___________________________________

~ THIS AGREEMENT AFFECTS YOUR LEGAL RIGHTS;

PLEASE READ IT CAREFULLY AND SIGN ONLY IF YOU

UNDERSTAND AND AGREE TO ITS TERMS ~

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2015 Release And Assumption Of Risks Agreement