Diver:  

Date of Birth:   (xx/xx/xxxx)

Address:  

Parent/Guardian:  

Phone Numbers - Home:    Work:    Cell:   (no spaces or dashes)

I, the undersigned, or as the parent or legal guardian of (a minor) hereby authorize such diagnosis, medical and/or surgical treatment for myself or such minor as may be considered necessary or appropriate under the circumstances for the treatment of any illness or injury of the minor.  Thunderbird Diving Club, its coaches, or employees shall not be responsible in any way for any consequences from said diagnostic, medical and/or surgical treatment and are hereby released from any and all claims and causes of action that may arise, grow out of, or be incident to such diagnosis, treatment, or surgery insofar as the law allows and provided that these services are performed with ordinary care and to the best of their ability.

By checking this box and typing your name, you confirm that you have read and agree to be bound by the terms and conditions as outlined in the Thunderbird Diving Club “Consent for Treatment” form  (above) and confirm that your electronic signature is the legal equivalent of your hand-written signature.   (electronic signature)   Date:  (xx/xx/xxxx)

Insurance Information

Company:       

Policy #:       

Group #: