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:

CHILDíS NAME __________________________________ BIRTH DATE__________

ADDRESS:_____________________________________________________________

PARENTíS NAME:_______________________________________________________

CHILDíS PHYSICIAN ____________________________________________________

CHILDíS ALLERGIC TO (IF APPLICABLE): ________________________________

OTHER APPROPRIATE MEDICAL INFORMATION, IF ANY___________________

 

LAST TETANUS OR DTP SHOT (IF AVAILABLE)____________________________  

I MAY BE REACHED AT :______________________WORK:____________________

 

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