Fill and Sign the This is an Important Document that Releases Your Form

RELEASE OF LIABILITY NOTE:THIS IS AN IMPORTANT DOCUMENT THAT RELEASES YOUR EMPLOYER FROM ALL CLAIMS FOR PERSONAL INJURY OR PROPERTY DAMAGE OCCURING DURING YOUR PARTICIPATION ON A SKI TRIP SPONSORED BY YOUR EMPLOYER. IT ALSO DESIGNATES AS AGENT TO CONSENT TO MEDICAL TREATMENT IN THE EVENT YOU ARE INCAPABLE OF DOING SO YOURSELF. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTOOD THE CONTENTS OF THIS DOCUMENT. UPON SIGNING, YOU SIGNIFY THAT YOU HAVE READ, UNDERSTAND AND AGREE TO ALL TERMS CONTAINED HEREIN. Employee Name: ______________________________________ Date of Birth:_____________Social Security # ________________________ Address:______________________________________________________City: __________________ State: _______ Zip: _________________Home Phone: ( )__________________Work Phone:( )_____________________Employee Consent:I, the undersigned, Employee of______________________________________, “Employer”, do hereby agree to participate in the Ski Trip to ____________________________ sponsored by Employer, and in consideration of being allowed to participate, assume the risk of personal injury to my person and for property damage to my Property.Authorization of Consent to Treatment: In the event of injury which renders me incapable of consenting to medical treatment, I, the undersigned, do hereby authorize ____________________________________, hereinafter "Agent", for and on behalf of the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician and surgeon licensed under the provision of the Medical Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or at a hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable. This authorization shall remain effective through the ____ day of ________________, 20____, unless sooner terminated in writing.Release of Liability:I agree to indemnify, hold free and harmless, assume liability for, and defend Employer, its agents, servants, employees, officers, and directors from any and all costs and expenses including but not limited to, attorney's fees, reasonable investigative and discovery costs, court costs, and all other sums for any claim or action founded thereon, arising or alleged to have arisen out of my participation on the Ski Trip, or for any medial treatment rendered on consent of my agent designated above, and release Employer from payment or responsibility for same.Employee_________________________________________________ Date:______________ Signed Other Emergency Contact _______________________________Phone___________________Family Doctor__________________________________________Phone___________________Insurance Co._________________________________If None Please Check ______Insurance Policy Name and # ____________________________________________Known Medical Conditions _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________Medications?___________________________________________________________________Allergies?_____________________________________________________________________ Last Tetanus Immunization?________________________________Will You Allow Blood Transfusions? Yes____ No____ Other__________________________________________________________________________