Temporary Guardianship Waiver

Hidden Falls Adventure Park & Copperhead Creek Shooting Club
Authorization of Temporary Guardianship and Consent to Medical Treatment by Nonparent

By my signature hereto, I hereby give authority to the “Temporary Guardian” (named below) to consent to medical and/or dental treatment for the Child in the event I cannot be contacted. The Temporary Guardian is an adult who has the care and control of the Child.
Without limitation, any physician, surgeon, hospital or medical staff, emergency ambulance personnel and/or dentist may receive the consent hereby given in this authorization.
The date treatment is to begin is the date upon which the Temporary Guardian requests treatment be performed.
I acknowledge that the Child will reside with the Temporary Guardian and may travel locally with the Temporary Guardian and participate in off road and other outdoor motorized activities at Hidden Falls Adventure Park and/or shooting sports at Copperhead Creek Shooting Club, located at 7030 E. FM 1431, Marble Falls, Texas 78654.
I authorize the Temporary Guardian to act on my behalf in making all decisions on a daily basis as to the Child’s activities, well-being and welfare.
I authorize the Temporary Guardian to administer general first aid treatment for minor injuries or illnesses experienced by the Child except where any such first aid treatment is specifically excluded hereunder:

This authorization may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall include faxed versions of an original signature or electronically scanned and transmitted versions (e.g., via pdf) of an original signature.

Signee Information

First Name *

Last Name *

Mobile Number *

Address *

Address Line 2

City *

State *

Zip *

Home phone*

Mobile phone *

Cell phone*

I have authority to consent to medical treatment of the Child in that I am: *

Parent

Guardian of the Person

Managing Conservator of the Child(ren)

Information of the temporary guardian(s) are:

Name of temporary guardian*

Address, City, State, Zip*

Phone*

The date treatment is to begin is the date upon which the Temporary Guardian requests treatment be performed. This authorization terminates on:*

Enter date that authorization terminates

I authorize the Temporary Guardian to administer general first aid treatment for minor injuries or illnesses experienced by the Child except where any such first aid treatment is specifically excluded hereunder:

Please note that the Child has the following conditions:

The Child is presently prescribed or is being administered the following medications:

The Child’s medical insurance information is:

Medical Aid/Insurer:*

Policy Number:*

Name and address of Employer: *

Sign Here

By clicking 'I Agree' below, you agree that you have read and agree with the terms of the waiver and that the information you provided is accurate. You furthermore agree that your submission of this form, via the 'I Agree' button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.

Temporary Guardianship Waiver

Signee Information

Information of the temporary guardian(s) are:

The Child’s medical insurance information is:

Please enter participants' full names: