Whitewater Rafting Permission Form

                  METHACTON HIGH SCHOOL SWIM AND DIVE TEAM

                  POCONO WHITEWATER RAFTING TRIP

                  SUNDAY OCTOBER 4, 2009

                  POCONO WHITEWATER JIM THORPE PA 1-800-944-8392

NAME __________________________________________  
D.O.B.________________________________

 Emergency Contacts:

• Primary Emergency Contact      ________________________________
  • Relationship to athlete:     __________________________
  • PHONE:                         ____________________
  • Alternate PHONE:          ______________________________

• Alternate Emergency Contact   ________________________________
  • Relationship to athlete:    __________________________
  • PHONE:                        ____________________
  • Alternate PHONE:         ______________________________

Medical Insurance Info:             Policy Holder’s Name:  ________________________

Provider:  ___________________________________

                                                Policy/Group #:   _____________________________

I give my permission for the above individual to participate in the white water rafting trip.

In the event that a parent or Emergency contact can not be reached, I give my permission for the above individual to obtain emergency medical care as needed.

Signature of Parent/Guardian:   _____________________________________