SUNDANCE FARM EMERGENCY PRE-CONSENT FORM

__________________________________ OF _________________________________

  (PARENT\GUARDIAN)                                         (CHILD)

HEREBY CONSENT TO AND AUTHORIZE EMERGENCY TREATMENT WHICH YOU JUDGE AS NECESSARY FOR MY CHILD.  ADDITIONALLY, I AUTHORIZE THE RELEASE OF MEDICAL INFORMATION REQUIRED BY ANY THIRD PARTY IN CONNECTIONS WITH THE PAYMENT BY IT OR ANY PORTION OF THE RELATED HOSPITAL BILL.

THIS AUTHORIZATION SHALL BE VALID FROM THIS DATE, _______________ UNTIL SUCH TIME AS MY CHILD IS NO LONGER TAKING LESSONS AT SUNDANCE FARM.

________________________________________________ DATE_________________                (HOME ADDRESS) 

INFORMATION:

CHILD’S NAME __________________________________ BIRTH DATE__________

ADDRESS:_____________________________________________________________

PARENT’S NAME:_______________________________________________________

CHILD’S PHYSICIAN ____________________________________________________

CHILD’S ALLERGIC TO (IF APPLICABLE): ________________________________

OTHER APPROPRIATE MEDICAL INFORMATION, IF ANY___________________

LAST TETANUS OR DTP SHOT (IF AVAILABLE)____________________________  

I MAY BE REACHED AT :______________________WORK:____________________