CAÑON
CITY AREA METROPOLITAN RECREATION AND PARK DISTRICT
EMERGENCY
MEDICAL FORM
PLEASE PRINT NAME_____________________________________________ GRADE
________ DATE________________________
BIRTHDATE___________________________AGE ________ HOME PHONE # ____________________
GENDER: M ٱ F ٱ
ETHNICITY: ٱ Caucasian ٱ
Hispanic/Latino ٱ Black/African American ٱ American Indian or
Alaskan Native ٱ Asian or Pacific
Islander
Other______________
PARENT/GUARDIAN’S NAME
___________________________________________________________________________________
ADDRESS
_____________________________________________________________________________________________________
PHONE # DURING DAY: FATHER’S_______________________________
MOTHER’S_____________________________________
IN AN EMERGENCY, IF PARENTS CANNOT BE CONTACTED:
NOTIFY (NAME)________________________________________________ AT (PHONE
#)__________________________________
FAMILY DOCTOR_______________________________________________AT (PHONE
#)__________________________________
KNOWN ALLERGIES ___________________________________________________________________________________________
DESCRIBE ANY PHYSICAL CONDITION REQUIRING THE FACILITY’S SPECIAL
ATTENTION: _________________________
_______________________________________________________________________________________________________________
I do
hereby authorize officials of the Cañon City Area Metropolitan Recreation and
Park District to contact directly the person named on
this application, and do authorize the named physician
of his/her associate to render such medical treatment a my be deemed necessary
in an emergency for the health of said child. In the event the
parents/guardian/alternate persons/ physician named on this application cannot
be reached, the Cañon City Area Metropolitan Recreation and Park District
officials are hereby authorized to take whatever action is deemed necessary in
their judgment for the health of the aforesaid child. I agree I am solely
responsible for payment of all costs resulting from the rendering of medical
and ambulance services.
I HAVE READ THE STATEMENT AND AGREE TO THE
STATEMENT AS IT IS WRITTEN.
Signature of
Parent/Guardian________________________________________________ Date
___________________________________
PERSONAL RELEASE STATEMENT:
In consideration of accepting my child’s entry or
participation, I hereby, for myself, my child and child’s heir, executors and
administrators, waive and release any and all rights and claims for damages my
child may have against the Cañon City Area Metropolitan Recreation and Park
District, its representatives, successors, and assigns for any and all injuries
suffered by my child at any activity sponsored by this program, whether based
on negligence or otherwise, and I agree to indemnify the District (and its
representatives, successors, and assigns) against any and all claims for such
loss, damages or injury.
Signature of
Parent/Guardian________________________________________________Date__________________________________
CAÑON
CITY AREA METROPOLITAN RECREATION AND PARK DISTRICT
EMERGENCY
MEDICAL FORM
PLEASE PRINT NAME_____________________________________________ GRADE
________ DATE________________________
BIRTHDATE___________________________AGE ________ HOME PHONE #
____________________ GENDER: M ٱ
F ٱ
ETHNICITY: ٱ Caucasian ٱ
Hispanic/Latino ٱ Black/African American ٱ American Indian or
Alaskan Native ٱ Asian or Pacific
Islander
Other______________
PARENT/GUARDIAN’S NAME
___________________________________________________________________________________
ADDRESS
_____________________________________________________________________________________________________
PHONE # DURING DAY: FATHER’S_______________________________
MOTHER’S_____________________________________
IN AN EMERGENCY, IF PARENTS CANNOT BE CONTACTED:
NOTIFY (NAME)________________________________________________ AT (PHONE
#)____________________________________
FAMILY
DOCTOR_______________________________________________AT (PHONE
#)____________________________________
KNOWN ALLERGIES ___________________________________________________________________________________________
DESCRIBE ANY PHYSICAL CONDITION REQUIRING THE FACILITY’S SPECIAL
ATTENTION: _________________________
_______________________________________________________________________________________________________________
I do
hereby authorize officials of the Cañon City Area Metropolitan Recreation and
Park District to contact directly the person named on
this application, and do authorize the named physician
of his/her associate to render such medical treatment a my be deemed necessary
in an emergency for the health of said child. In the event the
parents/guardian/alternate persons/ physician named on this application cannot
be reached, the Cañon City Area Metropolitan Recreation and Park District
officials are hereby authorized to take whatever action is deemed necessary in
their judgment for the health of the aforesaid child. I agree I am solely
responsible for payment of all costs resulting from the rendering of medical
and ambulance services.
I HAVE READ THE STATEMENT AND AGREE TO THE
STATEMENT AS IT IS WRITTEN.
Signature of
Parent/Guardian________________________________________________ Date
___________________________________
PERSONAL RELEASE STATEMENT:
In consideration of accepting my child’s entry or
participation, I hereby, for myself, my child and child’s heir, executors and
administrators, waive and release any and all rights and claims for damages my
child may have against the Cañon City Area Metropolitan Recreation and Park
District, its representatives, successors, and assigns for any and all injuries
suffered by my child at any activity sponsored by this program, whether based
on negligence or otherwise, and I agree to indemnify the District (and its
representatives, successors, and assigns) against any and all claims for such
loss, damages or injury.
Signature of
Parent/Guardian________________________________________________Date__________________________________