As the parent, agency representative, or legal guardian, I hereby give consent to the

Bay Area Water-ski club (BAWSC) event chair _________________________________
to provide all emergency dental or medical care prescribed by a duly licensed physician
or dentist for the child listed below. This care may be given under whatever conditions
are necessary to preserve the life, limb, or well being of my dependent.



Child's Name: _______________________________________

  Birth date: ______________



     Address: ____________________________________________

        City: ___________________________________

       State: _____

         ZIP: ____________



   Allergies: __________________________________________________

 Medications: _______________________________________________





Mother: _______________________________________ Phone: ________________

Father: _______________________________________ Phone: ________________



Doctor: _______________________________________ Phone: _________________

Insurance Policy No: __________________



Dentist: ______________________________________ Phone: _____________________

Insurance Policy No: ________________



Emergency Contact: _____________________________________

Relationship: ______________

Phone: ____________________





________________________________         __________

Signature                                 Date