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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*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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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*
Parent or Guardian's 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.


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