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MEDICAL RELEASE AND INFORMATION
NAME ____________________________________________________________
ADDRESS _________________________________________________________
CITY _____________________ STATE _______________ ZIP _____________
HOME PHONE ___________________ CELL ___________________________
EMAIL ______________________________________
EMERGENCY CONTACT NAME _____________________________________
EMERGENCY CONTACT PHONE ____________________________________
INSURANCE COMPANY _____________________________________________
POLICY (ID) NUMBER _____________________ PHONE _________________
DR. NAME ____________________________ PHONE ______________________
Information about you that a treating physician should know such as allergies, medications, known conditions, etc. to be used in emergency treatment situations. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
By signing below I hereby authorize personnel to act according to their best judgment in any emergency on my behalf if I am unable to do so. I understand that I may be transported by GMAPA Inc., SCMC or others to a medical facility and I hereby waive and release them from any and all liability for any injuries sustained or illnesses while mining or while being transported.
I have no knowledge of any physical or mental condition that would prevent my safe participation in any activity at Duffy’s Adventures or in air or land transportation. I further acknowledge that any medical or transport expenses incurred will be my responsibility for both myself and my family.
Signed ________________________________ Date __________________________ |