Parent / Grandparent
Parent / Grandparent
Address *
Address
Phone
Phone
Student 1 *
Student 1
Student 2
Student 2
Student 3
Student 3
The undersigned parent or guardian of ________________________________, a minor, does hereby consent to any emergency X-Ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any physician and surgeon licensed under the Provision of the Medical Practice Act. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but, is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his or her best judgment may deem advisable; and neither said agent nor any organization involved assumes any financial responsibility for exercising this action.
Phone
Phone
Emergency Contact
Emergency Contact
Phone
Phone
Checkbox 1
IN CONSIDERATION of the Weatherby Lake Yacht Club providing the facilities, equipment, and personnel for the sailing classes, races, regattas and related activities being held during May, June, July, and August 2016, the undersigned; RELEASES, WAIVES, DISCHARGES, AND COVENANTS NOT TO SUE the Weatherby Lake Yacht Club, the Weatherby Lake Improvement Company, the City of Weatherby lake, their officers, directors, owners, employees, agents, or volunteers (herein after referred to as Weatherby Lake) from any and all loss, expense, cost, damage, obligation or claim arising out of or resulting from the injury or death to the person or property of the undersigned whether or not caused by an act or failure to act on the part of Weatherby Lake during or related to the aforementioned activities and further; AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS Weatherby Lake from any liability or damage the undersigned may suffer as a result of all activities taking place at Weatherby Lake.
Name *
Name