Snowball Express Letter of Consent To attend and travel with other than Parent or Guardian Medical Power of Attorney
Please print clearly!
I, ______________________________, as parent or guardian of minor child/ren: ____________________________________/______________________________ ____________________________________/_____________________________,give my authorization for the above child/ren to travel to and attend Snowball Express 2008 with__________________________________, who also has my express permission to authorize and sign for emergency medical care and/or treatment that may be required in the event I cannot be reached. This consent is in effect from December 15, 2008 to December 21, 2008.
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Signature of Parent/Guardian
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Date signed
Home phone number________________________ Cell phone number__________________________ This form must either be witnessed by another adult person other than the parent or guardian or it must be notarized. Witnessed by: Name: ______________________________ Address:
THE STATE OF _________________ § COUNTY OF ___________________ § BEFORE ME, the undersigned authority, on this day personally appeared _____________, and he/she, after first being duly sworn by me, on their oath stated that he/she signed this Medical Power of Attorney for the purposes and considerations stated within the document, to which witness my signature and seal of office this ______ day of _______________, 2008. __________________________________________ Notary Public in and for the State of ____________
Printed Name: ______________________ My Commission Expires: ________________ Please sign, have witnessed and notarized and Fax to: Snowball Express 714‐662‐2033 Or mail to: Snowball Express 2973 Harbor Blvd. #401 Costa Mesa, CA 92626‐3912