Multi-Release Form for Pats Peak Program
Student Name: _________________________________________________ Parent Phone #s: ________________________________________________ Parent email: ___________________________________________________ Please indicate the plan for your child should the program be cancelled due to inclement weather (home, day care, homework club etc.). ________________________________________________________________________
Dismissal Release Check One
_____My child has my permission to be dismissed from the classroom at 2:25 PM to board the bus to Pats Peak. _____My child will be riding to Pats Peak with parent and not taking bus.
Transportation home from Pats Peak
Please indicate how and when your child will leave Pats Peak each Thursday.
Emergency Medical Release Form
I hereby grant permission to Laurie Prewandowski, Rachel deThomas and/or W.Y.S.A. designated chaperones to secure such medical care as ________________________ (name of child) may require beginning on January 3, 2008 and continuing until the completion of the 5 sessions as scheduled by Pats Peak. This gives permission to Pats Peak Ski Patrol, any responding ambulance service and/or Concord Hospital to provide emergency treatment for your child in the event of illness or injury. Every attempt will be made to contact the legal guardian listed. Emergency treatment, however, will not be delayed while trying to make this contact. List any current medical conditions: List any current medications: List any allergies:
Signature of legal guardian: _________________________________________ Date _________________