Parent/Guardian Name:

Student Name:

Mailing Address:

Phone:

Date of Birth:

Family Physician:

Are there any special needs that may help us avoid health or medical problems?

In case of an emergency, what other relative or friend may be called?

Name:

Phone

Relationship

I/We, (Parent(s)/Guardian(s) give my permission for (Student) to join this group ski program, and I/we authorize Teton Pass Ski Area, Inc, Staff to obtain or administer medical treatment for her/him in the event of an emergency. She/He may participate in group ski activities. We hold Teton Pass Ski Area, Inc, harmless from an liability for injuries sustained in connection with the activities set forth in this document, unless said injuries are due solely to the intentional misconduct or gross negligence of Teton Pass Ski Area, Inc.

Signature_____________________________________________________________

Date__________________________________________________________________