SWSC 2015-2016 Medical Release and Consent to Treat

Please submit the form below.

* indicates required field

Date:*

Parent/Guardian's Name:*

Child's Name*

Age:*

Grade:*

Address:*

City, State, Zip Code:*

Contact Number:*

Skill Level*

I, Beginner II, Intermediate III, Expert

Email:*

By clicking the check box in the “I Accept” box below, I certify that I am the Participant or that I am the parent or legal guardian of the participant and that I hereby authorize Sunlight Winter Sports Club to enlist qualified medical professionals to provide all emergency medical and/or surgical treatment that may be required for our child/children during our absence or for myself if I am the participant from November until April.*

I Accept

Preferred Physician:*

Physician's Number:*

Emergency Contact:*

Relationship:*

Contact's Phone Number:*

Allergies:*

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