Medical Authorization for Minors

Directions –

Please complete the form below, note that all form elements are mandatory.
You will receive a copy of this authorization at the email used for the Parent/Guardian. (The club’s coaches will also receive a copy.)
Please remember to review the information you provide to us annually, and if needed, update the information if something has changed.

Today's Date:

Minor's Name:

Minor's Birthdate:

Parent or Guardian's Name:

Relationship: ParentGuardian

Parent/Guardian Email:

Confirm Email:

PRIMARY CARE INFORMATION:

Physician Name:

Physician's Phone:

Health Insurance Provider:

Policy Number:

MEDICAL HISTORY:

Allergies (If none known, put "none"):

Medications (If none known, put "none"):

Medical Concerns (that we should be aware of):

PRIMARY EMERGENCY CONTACT:

Name of Primary:

Primary Contact's Phone:

ALTERNATE EMERGENCY CONTACT:

Name of Alternate:

Alternate Contact's Phone:

In the case of an accident or illness, I hereby give permission for the minor listed above to be given emergency treatment. I understand that the Ventura Canoe & Kayak Club, their coaches, and board members assume no liability or financial obligation with respect to such rendering of services. In the event that I, or the designated alternate, cannot be contacted, I further authorize and consent to the administration of any and all medical and surgical examinations or operations and treatment or all related care, including the administration of tests, anesthesia, and/or blood transfusions, to the above-named minor which may be ordered by the physician in attendance at the medical center deemed necessary for emergency treatment.
I hereby consent to the release of any medical report(s) to any doctor or agency and consent to the admission of the above-named minor to the hospital.

By clicking the submit button below the Parent or legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.

Electronic Signature Consent (Printed)

Enter your legal name in the field below

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. 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.

Click the button below to submit this form. (It won't work if you haven't checked the Electronic Signature Consent box above.)
You will receive a copy of this form via the email address you entered above.