Emergency Contact Form Please enable JavaScript in your browser to complete this form.Rider's NameFamily Physician NamePhysician AddressPhysician Phone Number Preferred Hospital Emergency Contact One NameEmergency Contact One NumberEmergency Contact Two NameEmergency Contact Two NumberPERTINENT MEDICAL HISTORY: We ask the following information so in the event we needed to call 9-1-1 and you could not answer for yourself, we could give medically necessary information to the Paramedics in a timely manner. (Check all that apply)Previous history of concussionsFainting episodes during exerciseEpileptic/SeizuresWears glassesAre lenses shatterproof?Wears contact lensesWears dental applianceHearing problemAsthmaInhaler?Trouble breathing during exerciseHeart ConditionDiabeticAllergiesBee or wasp AllergiesEpiPenWears a medic alert bracelet or necklaceSurgery in the last yearHas been in hospital in the last yearPresently injuredHas had an illness lasting more than a week in the past yearAny health problem that would interfere with participation in Horse riding?Has had injuries requiring medical attention in the past year.If you answered ‘Yes’ to any of the above items, please explain/ additional information not covered above:Relevant Medication: (inhaler, epicenter, etc. please list: name, dose, frequency):Allergies: (food, medicine, environmental):Relevant Medical Conditions: please above: emergency, Last Tetanus Shot:***In case of emergency, if family physician cannot be reached, I herby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, E.R Physician). I hereby authorize the physician and medical staff to undertake examination, evaluation, diagnostic testing and necessary treatment of my child. I also authorize release of information to appropriate people (instructors, physician…) as deemed necessary. ***Authorized Parent/Guardian’s Signature:DateSubmit
