Tide’s
End Farm
Completion of this form is required of any individual riding at Tide’s End Farm. Both sides must be completed including either Part I or Part II on the reverse.
NAME: ___________________________________________ AGE:______________
ADDRESS:______________________________________________________________
PARENT/GUARDIAN:__________________________________________________
ADDRESS:______________________________________________________________
PHONE 1):___________________________ 2)_________________________________
IN THE EVENT OF ACCIDENT, CALL:______________________________________
PHONE 1):___________________________ 2)_________________________________
HEALTH INSURER:______________________________________________________
FAMILY PHYSICIAN:__________________________________________________
MD/DO ADDRESS/PHONE:______________________________________________
PREFERRED HOSPITAL:_______________________________________________
PLEASE, COMPLETE The Consent Portion
TIDE’S END FARM
EMERGENCY TREATMENT RELEASE FORM
DESCRIBE HERE EXISTING MEDICAL CONDITIONS, ALLERGIES, MEDICATIONS OR INFORMATION OTHERWISE RELEVANT TO PROVISION OF MEDICAL CARE. THIS INFORMATION MUST BE COMPLETE AS IT WILL BE PROVIDED TO A MEDICAL PROFESSIONAL CARING FOR YOU.
IF NONE, PLEASE WRITE IN “NONE”.
PART I – CONSENT
In the event of medical emergency, the undersigned authorizes agents of Tide’s End Farm to take any necessary steps to obtain medical assistance, including use of an ambulance or emergency medical technical assistance.
The undersigned further authorizes any licensed physician and/or medical facility to provide any medical/surgical care or hospitalization, which they determine to be necessary or advisable, pending production of a specific consent from the undersigned.
_______________ ______________________________________________________
Date Signature
PART II – REFUSAL
The undersigned does not consent to the provision of medical treatment. In the event of illness or injury requiring emergency treatment, no action should be taken or: (described action desired)
_______________ ______________________________________________________
Date Signature