Medical release — WESPINE STUDY CENTER

Personal Information

Medical Insurance Company

Medical Insurance Group Number

Medical Insurance Policy Number

Medical Insurance Phone Number

Electronic Signature for Medical & Photo Release

As the parent or legal guardian of the participant identified on this registration, I hereby delegate authority to the Directors of Wespine to arrange whatever medical treatment they deem necessary for him during the activity. Also, I hereby authorize and consent to the use and reproduction by Wespine staff or an authorized agent or assignee of any and all photographs taken of the above-named applicant for the purpose of promoting Wespine programs, without any compensation to me. All film, together with any prints, shall constitute property of Wespine, solely and completely.