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AUTHORIZATION FOR MEDICAL/SURGICAL TREATMENT


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AdultMinor
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AUTHORIZATION FOR MEDICAL/SURGICAL TREATMENT

I, 


(First Name of Parent or Guardian) *

Last name of parent or guardian

being the custodial parent and/or legal guardian of


(First Name of Child) *

Last name of minor

, born


(Minor Date of Birth) *

in


(State of Minor Birth) *

And pursuant to I.C. 16-36-1-1 et seq., do hereby authorize


(First and Last Name of authorized adult accompanying minor to park) *

and/or


(Name of additional authroized adult accompanying minor to park, if applicable)

to consent to and secure for or on my behalf medical and/or surgical treatment for our child.


The consent of any person listed below shall be the equivalent of consent by us personally and any physician, hospital, clinic or other medical establishment, including emergency medical personnel, may relay upon said consent in rendering medical treatment to said child, including, but not limited to, diagnoses, treatment, medication and surgery.

This consent shall remain in effect until revoked in writing by the undersigned but nore more than sixty (60) days from the date of execution. These forms must be done each time the minor visits.

The adult person/s authorized to secure, and must accompany while riding, for and on our behalf medical and/or surgical treatment for and on behalf of our children are:


_______________________________     _________________________________

Printed Name of Authorized Adult              Printed Name of Authorized Adult


_______________________________        _________________________________

Signature of Authorized Adult                      Signature of Authorized Adult

(**Signature of authorized person(s) must be obtained at the time of arrival to the Badlands Off Road Park. 

Please do not sign this prior to arrival.)

Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*

Emergency Contact's Relation to Participant
Insurance

Insurance Carrier*

Insurance Policy Number*
First Parent or Legal Guardian Name

First Name*

Last Name*
First Parent or Legal Guardian Date of Birth*
First Parent or Legal Guardian Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*

Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


I affirm under the pains and penalties of perjury that the forgoing representations are true and correct.



By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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