Emerald Hollow Therapeutic Riding Center, Inc.

235 Run Hill Road, Brewster, MA 02631

(508) 896-0064

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

 

Participant’s Name: ____________________________________________ Date of Birth: ___/___/___ Age: _________ Weight: _______ Height: _______

Special Needs: _________________________________________________________                                                                                                           

 Primary Contact Name: ________________________________________ Relation: ______________________________                                                   

Mailing Address: Street __________________________________ City _________________ State _____ Zip _________                                                       

Home Phone: (     ) _________________ Cell Phone: (      ) _________________ Email: ________________________                                                                     

In the event of an emergency Preferred medical facility: ____________________________________________________________________________

Emergency Contact 1: ___________________________________________ Relationship: _________________________ Home Ph: ___________________

Work Ph: _________________ (ext) ____ Cell Ph: ____________________________                                                                                                         

 Emergency Contact 2: ___________________________________________ Relationship: _________________________ Home Ph: ___________________                                   

Work Ph: _________________ (ext) ____ Cell Ph: ____________________________

In the event emergency medical aid/treatment is required due to illness or injury while receiving services, or while on the property of EHTRC, I authorize EMERALD HOLLOW THERAPEUTIC RIDING CENTER, INC. to: 1. Secure and retain medical treatment and transportation, as needed. 2. Release participant’s records upon request to the authorized individual or agency involved in the medical emergency treatment. Consent and Authorization This release and authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed “life saving” by the physician or other licensed medical provider. This consent will only be used if the person(s) listed as emergency contacts cannot be reached. Date: ______________________ Consent Signature (Client, Parent, or Legal Guardian): _____________________________________________________