Emergency Pre-Consent Form

Parent / Guardian/ Adult Rider Name

First Name

Last Name

If applicable: Child's Name

First Name

Last Name

Rider's Birthdate

YYYY

Rider's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Phone Number

(###)

###

####

Rider's Physician

Preferred Hospital:

Rider Allergies:

Other Appropriate Medical Information:

Last DTP or Tetanus Shot:

If applicable

YYYY

I 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.

YYYY

By typing my legal name on the field below, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By entering my legal name using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian.

Legal Name Representing Signature of Rider (if adult) / Guardian/ Parent:

Electronic Signature Date

YYYY