Step 4. Emergency Medical Authorization

Applicant's 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 Phone *

(###)

###

####

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

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

(###)

###

####

Medical Treatment Consent & Release *

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 Topping Riding Club, 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.

Medical Procedures Consent *

I authorize 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.

Date *

MM

DD

YYYY