Fill in date of camp________________.
Camper's name:________________________ Birthday__________
Grade in school______________
Address: _________________________________________________
City: _____________ State ________ Zip _____________
Email _________________________
Paren/Guardian Signature____________________
(Registration must include the following consent form completed)
Horse Consent Form for 'Rice's Horses & More Outreach"
I _________________ (name of parent or guardian) acknowledge and understand the risks and potential risks of horseback riding and handling of horses. However, I feel that the possible benefits to myself/child/ward are greater than the risks assumed. I hereby, intend to be legally bound, for myself, my heirs, and assigns, executors or administrators, waive and release forever all claims for damages against 'Rice's Horses & More Outreach" for any and all injuries and/or losses of myself/child/ward may sustain while participating in these events.
____________________________
Parent/Legal Guardian signature
Consent plan:
In the event emergency medical aid/treatment is required due to illness or injury during activities or while being on the property of the agency, I authorize the staff of 'Rice's Horses & More Outreach" to:
1. Secure and retain medical treatment and transportation if needed.
2. Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.
Camper's name: ______________ Phone # _________________
Person to contact in case of emergency: _______________.
Phone #'s _________________________________
Health Insurance Carrier: _____________________
Group ID # ______________________
This authorization includes x-ray, surgery, hospitalization, medication, and any treatment procedure deemd 'life saving' by the physician. This provision will only be invoked if the person listed below is unable to be reached.
Date signed __________ Consent Signature __________________
Printed name of Signature person __________________________.
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