Massachusetts Medical Release Form 3
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MASSACHUSETTS SKI CLUB, INC
MEDICAL RELEASE
I, _________________________________ of _______________________________________
STREET
____________________________________________________________________________
TOWN
STATE
ZIP CODE
_______________________am the parent/guardian of ________________________________.
TEL NO.
I give and authorize the Massachusetts Ski Club, Inc., its agent, employees, or representatives to
authorize medical treatment for my child, including but not limited to x-rays and medical
treatment related to skiing accidents and/or emergency medical treatment recommended by
hospitals or doctors.

My child’s primary care physician is ______________________________________________
his/her address is ____________________________________________________________
___________________________
Tel. No.
I do/do not wish the physician to be contacted if treatment is required if possible.
In Witness Whereof, I have set my hand and seal this __________ day of ____________
(month), __