Loading...

Emergency Medical Information

This information is kept on file in case of emergency. This form is particularly recommended if you attend our events by yourself. If the information supplied in the past is still current, there is no need to re-submit until insurance or contact information changes.

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Insurance
Insurance Carrier*
Insurance Policy Number*
General Medical Information
Blood Type if known
Current Prescription Medications
Previous Injuries or Medical Conditions
Abdomen
Arms - broken or dislocated
Asthma
Back
Blood Pressure
Chest
Concussions
Contacts
Dentures
Diabetes
Epilepsy
Head
Head Injury
Hearing
Heart
Legs - broken or dislocated
Neck
Allergies or Other Conditions
Emergency Contacts
Emergency Contact #1
Emergency Contact #1 Phone Number
Emergency Contact #2
Emergency Contact #2 Phone Number
Horse Information
Barn Contact
Barn Phone Number
Veterinarian
Veterinarian Phone Number

I am the mother, father, or legal guardian of the child/children named above. I hereby give my consent to medical treatment that is necessary to save the life or medically treat the minor child.

PERSON SIGNING THIS WAIVER ON BEHALF OF THE MINOR MUST BE THE PARENT OR LEGAL GUARDIAN.




Parent or Guardian's Name
First Name*
Last Name*
Relationship*
Phone*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!