MASSACHUSETTS SKI CLUB, INC
I, _________________________________ of _______________________________________
_______________________am the parent/guardian of ________________________________.
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 ____________________________________________________________
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 ____________