Session Attending: session 1session 2session 3Other
Date of Birth:
Resident of the City of Scottsdale: YesNo
Contact number in the event of a late cancellation:
To Whom It May Concern:
In the event of an emergency or non-emergency situation requiring medical treatment, I/We hereby grant permission for any and all medical attention to be administered to my child ; date of birth in the event of an accidental injury or illness, until such time as I can be contacted. This permission includes, but is not limited to the administration of first aid, the use of an ambulance, and the medical or surgical diagnostic or treatment procedure deemed necessary by an Emergency physician at a licensed hospital. I understand that any resulting expenses or charges are my responsibility and I will pay them immediately, either directly or through personal insurance.