AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT FORM

In the event emergency medical aid/treatment is required; due to illness or injury during the course of giving or receiving lessons or while being on the property of the agency, I authorize Paradise Ranch to:

1. Secure and retain medical treatment and transportation if needed.
2. Release rider's records upon request to the authorized individual or agency involved in the medical emergency treatment.

Name:  Relationship:  Rider Volunteer Employee select one  

Address:   City:  State:  Zip:

Email:  Phone:

Parent or Guardian (if applicable):  Phone:

In the event I cannot be reached:

     Contact:  Phone:

     Contact:  Phone:

Physician’s Name:  Phone:

Preferred Medical Facility:

Health Insurance Co:   Policy No:

CONSENT PLAN:

 I do give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency. This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed emergency medical treatment by the physician. This provision will only be invoked if the person listed below is unable to be reached.

Signature:   Relationship:  Rider Volunteer Employee select one  Date:

Address:   Phone:

NON CONSENT PLAN: (Alternative)

 I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency. In the event emergency treatment/aid is required, I wish the following procedures to take place:

Signature:   Relationship:  Rider Volunteer Employee select one  Date:

Address:   Phone: