1738 Consent For Medical Treatment In Canada YL1738

User Manual: 1738

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YL-1738 11/09 Printed in U.S.A.

CONSENT FORM FOR MEDICAL

TREATMENT IN CANADA

GOVERNING LAW

I hereby agree that the relationship and the resolution of any and all disputes arising there from

between myself and the Malibu Club physicians relating to medical treatment received during

the week of _________________________ shall be governed by and construed in accordance

with the laws of the Province of British Columbia. To obtain a copy of Young Life’s Notice of

Privacy Practices, log on to HTUwww.younglife.orgUTH or call (719) 381-1953.

JURISDICTION

I hereby acknowledge that any complaint, demand, claim or cause of action, whether based on

alleged breach of contract or alleged negligence arising out of any medical treatment received

from the Malibu Club physicians, would be governed by the jurisdiction of the Province of

British Columbia.

By signing this statement, I hereby understand and agree that if I commence any such legal

proceedings, they will be limited to the exclusive jurisdiction in the Courts of the Province of

British Columbia.

__________________________________ __________________________________

Name Signature Date

All minors visiting Malibu Club must have this form signed by their parent/guardian prior

to leaving for camp.

YOUNG LIFE SHALL NOT BE HELD LIABLE AT ANY TIME FOR LOST OR STOLEN LUGGAGE OR

PERSONAL ITEMS.

___________________________________ ____________________________________

Parent’s Signature Date Witness Signature

(Notary not required) Date

URequired for minorsU URequired for minorsU

___________________________________ ____________________________________

Parent’s Printed Name Witness’ Printed Name