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 *

(###)

###

####

Parent or Guardian Name

Only required if applicant is under 18

First Name

Last Name

Parent or Guardian Phone

Only required if applicant is under 18

(###)

###

####

Parent or Guardian Address

Only required if applicant is under 18 and if different than address 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 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 Treatment Consent *

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)

Date *

MM

DD

YYYY