Parent Consent

I consent to my child’s participation in the use of Score Hockey Range. I am aware there are risks associated with participation in Score Hockey Range, including risk of injury, and I consent to my child’s participation in spite of such risks.

I acknowledge that it is my responsibility to advise Score Hockey Range of any medical or other conditions that may affect my child’s participation in Score Hockey Range.

In the event that my child requires medical attention, I consent to my child being transported to the nearest emergency center including by ambulance if necessary, and accept that I am responsible for any costs of such ambulance service.

I have read this Parental Consent Form and understand and accept its terms.

Parent or Guardian*
First Last
Signature*
Minor's Details
Name*
First Last
Address*
Street Address Address Line 2 City Province Postal Code
Phone*
Email*
Date of Birth*

Day
Month
Year
Parent/Guardian Details
Name*
First Last
Address
Same as minor's address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Medical Information
Alberta Health Care Number
Family Doctor*
Doctor Phone Number*
Emergency Contact Name*
Emergency Contact Phone*
Relationship to Minor*
Does your child currently have any medical problems? Please Explain.*
Is your child currently taking medications? Please List.*
Does your child often feel faint or dizzy?*
Does your child have any bone or joint problems that made worse by exercising?*
Does your child exhibit any of the following: shortness of breath, back pain, chest pain, coughing on exertion, heart palpitations?*
Does your child have any reason he or she should not participate in vigorous exercise?*

Parent Consent

Minor's Details

Parent/Guardian Details

Medical Information