R4, 2022-01-22

NOTE: Lake Tahoe Snowmobile Tours does not accept paper waivers, please submit electronically.

Release of Liability for Refusal of Care

Emergency Medical Personnel who ware being called to inspect your injury or dilemma are free at NO CHARGE TO YOU. Anything beyond their initial inspection can potentially incur a charge.

I, for Myself and/or on behalf of my child or legal ward, have been fully informed by Lake Tahoe Snowmobile Tours, Inc. (hereafter collectively referred to as “LTST”), of the potential consequences and/or complications that may result in refusal to accept medical assistance or emergency care. I have been given sufficient information about the current injury and/or condition, and understand the nature and the potential consequences of refusing care. I understand what has been explained about the injury and/or condition, and am capable of making a well-informed decision on my/the patient’s behalf, I further certify that I am voluntarily willing to assume the risk of any medical or physical condition. I (or my guardian), refuse to accept medical care or transport to a medical facility, and assume all risks and consequences resulting from my/ the patient’s decision. I understand that without treatment or delay of treatment the injury or condition may result in a worsened problem. I have been advised by LTST to seek the advice of a physician as soon as possible. I release LTST and all of those currently involved in my/the patient’s care from any liability regarding the eventual outcome of the medical problem or injury for which I (the patient) am refusing treatment and/or transportation to a medical facility.

Reason for Refusal of Care:



Signer Statement of Awareness

I/we the undersigned have read the foregoing statement carefully before signing and do understand its warnings and assumption of risks.

Click to Sign
Signature

WITNESSED BY

Click to Sign
WITNESS SIGNATURE