Child's Name: __________________________________________________________

Address:        __________________________________________________________

1st   ____________________________________   ____________________    ________
                        name                                                      number                   type (cell, work, home, etc.)

2nd   ____________________________________   ____________________    ________
                        name                                                      number                    type (cell, work, home, etc.)

3rd   ____________________________________   ____________________    ________
                        name                                                      number                   type (cell, work, home, etc.)

4th   ____________________________________   ____________________    ________
                        name                                                      number                   type (cell, work, home, etc.)


My child, _____________________________________________, has permission to go on a 3 day
weekend ski trip with Robert Carr on January 28-31, 2010.

Family doctor or clinic:    ________________________________________________

Phone:   ________________________________________________

Insurance coverage:    ________________________________________________

Policy number:   _________________________      Subscriber ID:  _______________________

Student's birthdate:   ______________________________

DRUG ALLERGIES OR SPECIAL MEDICAL INFORMATION:   __________________________________________

  _______________________________________________________________________________________

  _______________________________________________________________________________________

I, the undersigned parent or guardian of   ____________________________________, a minor, do hereby
authorize Robert Carr, as agent for the undersigned, to consent to any X-ray, examination, anaesthetic,
medical or surgical procedure or treatment and hospital care to be rendered to the foregoing minor in case
emergency medical treatment is needed, pursuant to the provisions of Section 25.8 of the California
Civil Code.

Signature of parent or guardian    ______________________________________ 

                                     Date     _______________________