Note: No racer will be
allowed to practice or race with the team unless this form is returned to the
racerŐs Level Coordinator (addresses below).
Name:
______________________________________________________________
Address: ____________________________________________________________
_____________________________________________________
City __________________________ Zip _________________
Telephone: ______________________________
Email: __________________________________________________________
Birth date (M/D/Y):
__________________ Age: __________
MotherŐs Name:
________________________________________
Address/Home Phone (if other
than above):
________________________________________________________________________________________________________________________________________________
MotherŐs Work
Phone: ____________________
FatherŐs Name:
________________________________________
Address/Home Phone (if other
than above):
_______________________________________________________________________________________________________________________________________________
FatherŐs Work Phone:
____________________
Emergency Contact (other than
parents): _________________________________________
Phone: ____________________
Health Insurance Carrier:
_________________________________________
Policy
#: _________________________________________
Are you taking any
medications? __________________________________________________
________________________________________________________________________
Do you have any allergies?
_______________________________________________________
________________________________________________________________________
Please give the date of your
last immunization for Tetanus _______________
Are you up-to-date on all
other immunizations as required by New York State Department of Education
athletic policies? Yes _____ No _____
Is there anything medically
we should know about? Please be specific.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please read the following authorization,
sign and return it to the racerŐs Level Coordinator. Thank you.
(To consent to treatment of
minor lacking capacity to consent)
I/we, the undersigned,
parent(s)/person having legal custody of/legal guardian of
___________________________________________ a minor, do hereby authorize
the Labrador Mountain Ski Club, Inc. as agent(s) for the undersigned to consent
to any X-ray examination, 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 provisions of the Medical Practice Act on the medical staff
of any hospital, whether such diagnosis or treatment is rendered at the office
of said physician or at said hospital.
It is understood that this
authorization is given in advance of any specific diagnosis, treatment, or
hospital care being required by is given to provide authority to power on the
part of our aforesaid agent(s) to give specific consent to any and all such
diagnosis, treatment or hospital care which a physician, meeting the
requirements of this authorization, may, in the exercise of his/her best
judgment deem advisable.
I/we hereby authorize any
hospital which has provided treatment to the above named minor to surrender
physical custody of such minor to my/our above named agent(s) upon completion
of treatment.
These authorizations shall
remain effective until April 30, 2010 unless sooner revoked in writing and
delivered to said agent(s).
Signature of parent(s)/legal
guardian(s)/person(s) having legal custody
_________________________________________________________ Date __________
_________________________________________________________ Date __________
If signed by other than
parent, please indicate relationship. _________________________
Send completed forms to:
J1-2: Julie
Moore, 95 East Lake Road, Skaneateles, NY 13152
J3: Susan
Batten
J4: Brigit
Bryant
J5: Bill
Kathy Elbadawi
Forerunners: Bring
to first Session