Authorization for Emergency Medical Treatment

Authorization for Emergency Medical Treatment
CONSENT PLAN
In the event emergency medical aid/treatment is required due to illness or injury while participating in the Prospect Riding Center program: I authorize Prospect Riding Center to secure and retain medical treatment and transportation if needed. This authorization includes but is not limited to x-ray, surgery, hospitalization, medication and any treatment deemed “life-saving” by the physician. In addition, I authorized Prospect Riding Center to release my records to any individual involved in medical treatment and/or transportation I might need. This provision will be invoked only if the emergency contact person(s) listed below is/are unable to be reached.

Date: _________ Participant’s Name (print) __________________________DOB: _______
Home Phone Number: (___) __________

Street Address: __________________________________________________________

City: ___________________________________ State: ________ Zip Code: __________
In case of emergency, contact:
Name: ______________________Relationship: _________ Phone Number(s): (___) _________

Name: ______________________Relationship: _________ Phone Number(s): (___) _________

Physician’s Name: _________________________________ Phone Number: (___) __________
Preferred Medical Facility: ________________________________________________________________
Allergies to Medications: __________________________________________________________________
Current Medications: ____________________________________________________________________

________________________________________________________________________

Health Insurance Company: ________________________________

Policy Number: ___________________
Consent Authorized Signature ______________________________ _____ Date:________
(Parent / Legal Guardian/Participant if over 18)
NON-CONSENT PLAN
I do not give my consent for emergency medical treatment in the case of illness or injury while participating in the Prospect Riding Center program. In the event of emergency treatment aid is required, I wish the following procedures to take place: (list procedures)___________________________________________________________________________
___________________________________________________________________________________
Date: __________________ Participant’s Name (print): _________________________________________
Parent or Legal Guardian will remain on site at all times during equine assisted activities.
Non-Consent Authorized Signature: _____________________________Date: __________
(Parent / Legal Guardian / Participant if over 18)