Authorization for Emergency Medical Treatment Name * First Name Last Name Date of Birth * MM DD YYYY Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Physician's Name, Town Physician's Phone (###) ### #### Health Insurance Company ID/Policy # Allergies to medication * Current Medications & Dosage * (we ask for this information strictly for the purposes of sharing with Emergency Medical Technicians in the event of an emergency, if necessary) Caregiver Name First Name Last Name Caregiver Phone (###) ### #### Caregiver Address (if different from above) Address 1 Address 2 City State/Province Zip/Postal Code Country In the event of an emergency, contact: (must provide at least one emergency contact) Emergency Contact #1 * First Name Last Name Emergency Contact #1 Phone * (###) ### #### Emergency Contact # 2 First Name Last Name Emergency Contact # 2 Phone (###) ### #### Emergency Contact # 3 First Name Last Name Emergency Contact # 3 Phone (###) ### #### In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the property of Twin Oaks Farm, I authorize Center for Therapeutic Riding in the East End (CTREE) to: 1. Secure and retain medical treatment and transportation if needed. 2. Release my medical, lesson records upon request to the authorized individual or agency involved in the medical emergency treatment. By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature. Consent Plan * This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed “life-saving” by the physician. This provision will only be invoked if none of the persons listed above are unable to be reached. (Parent or legal guardian signs if under 18) First Name Last Name Date * MM DD YYYY To my knowledge, the information I have given on this form is complete and accurate. * (Parent or legal guardian signs if under 18) First Name Last Name Thank you for submitting your Application! Someone from the CTREE Team will contact you soon. Please allow 1-2 weeks for your application to be processed.
