Medical Release
Skater Information
Camp Selection
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Learn to Skate Clinic
Hockey Clinic
Skater's Name
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First Name
Last Name
Skater / Parents Email
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Name of Physician
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Phone Number
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Address of Physician
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Dentist
Phone Number
Name of Orthodontist
Phone Number
Do you carry medical/hospital insurance?
Yes
No
If so, please indicate: Carrier
Policy/Group#
Operations or serious injuries (dates):
Chronic or recurring illness/medical condition:
Dietary Restrictions:
Current Medications:
Please indicate with a check if your child has experienced any of the following Allergies:
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Peanuts
Tree Nuts
Fish/Shellfish
Wheat
Egg
Milk
Soy
Mold
Animal
Dust
Insects
Other
Please indicate with a check (and dates if appropriate) if your child has experienced any of the following:
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Asthma
Frequent ear infections
Diabetes
Seizures/Epilepsy
Hypertension
Bleeding/Clotting Disorders
Mononucleosis
Heart Condition/Disease
Lyme Disease
None of the above
Other
Has your child had any of the following diseases (please give dates)
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Chicken Pox
Measles
German Measles
Mumps
None of the above
Other
Date(s)
WAIVER AND RELEASE
Medical Release
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This health history is correct as far as I know, and the person herein described has permission to engage in all camp activities except as noted. EMERGENCY AUTHORIZATION: I understand that in the event of an emergency affecting my child while participating in a City Ice Pavilion program, a designated employee of the City Ice Pavilion will attempt to contact me and inform me as soon as possible. In the event I cannot be reached, I hereby give permission for my child to be treated by a medical professional or hospitalized by a hospital selected by the City Ice Pavilion.
Liability Release
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Acknowledging that participation in athletics carries with it a risk of physical injury, I agree that City Ice Pavilion, its agents, and employees shall not be liable to me or my child for any injury or damage, howsoever caused, resulting directly or indirectly from my child’s participation in any and all City Ice Pavilion programming at any time preceding, during or after program is in session and I hereby discharge City Ice Pavilion, its agents and employees from all actions, claims, and demands I or my child may have for such injury or damage.
Publicity Release
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I authorize that City Ice Pavilion has the right to use all photographs or videos taken of my child during programming for advertising or promotional purposes.
COVID Release
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I hereby certify that to the best of my knowledge, (i) The skater has not been exposed to COVID-19 or the Coronavirus within the past month; (ii) No member of the skater’s family has shown symptoms of COVID-19 or the Coronavirus within the past month; and (iii) The skater has not shown such symptoms of COVID-19 or the Coronavirus within the past month. I agree that the skater may be withdrawn from program activities if the skater shows symptoms. I agree and acknowledge that the program has no obligation to ensure the prevention of exposure and/or symptoms. You and the skater are assuming the risk of any such exposure and/or symptoms. You acknowledge and agree that you have had the opportunity to become informed as to the risk of this virus, and are not relying on any assurance, representation, or promise of the program or its agents regarding such risks. I hereby, on behalf of the skater, the undersigned and the undersigned’s family, release City Ice Pavilion, its affiliates, the subject program, and any other program sponsor, and all employees, managers, operators, coaches, staff, facilities, and agents thereof, from liability, claims and lawsuits due to negligence arising from program attendance generally, and specifically with regard to any claims relating to COVID-19, the Coronavirus or any pandemic related illness or injury.
Signature [ Please print name]
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