Emergency Treatment Form Please submit the following, or if you prefer, download the .pdf form, print and mail to: Northland Therapeutic Riding Center P.O. Box 1267 Kearney, MO 64060 IN CASE OF EMERGENCY (Informatin will be kept confidential and used only in an emergency) No individual can be accepted as a Volunteer or Rider in Northland Therapeutic Riding Center's program until this form has been completed by his/her parent or guardian or by the individual if he/she is a legally competent adult age 18 or over. Riding instructions will be under strict supervision, and although every effort will be made to avoid any accident, no liability can be accepted by any of the individuals or organizations concerned or by Northland Therapeutic Riding Center or its personnel. Completion of this form constitutes permission for the named individual to participate as a volunteer or rider in the program. Name: Home Phone: Work Phone: Home Address: City: State: Zip: Parent/Guardian name (If under 18 years): Parent/Guardian Phone: Home Phone: Work Phone: Physician's Name: Physician's Phone: Allergies to any medications: Yes No If yes, please describe: Person who should be notified in case of emergency (please provide name in absence of parent or guardian): Name Home Phone: Work Phone: Relationship: AUTHORIZATION FOR PURPOSE OF PROVIDING MEDICAL TREATMENT You are being asked to complete this form to give an appropriate medical facility permission to treat for minor injury or medical problems. In the event of serious injury or illness, the parent/guardian or emergency contact listed above will be contacted; treatment will proceed before contacting them only if the situation is urgent and does not permit delay. Preferred medical facility: Insurance Company: In case of medical emergency, the undersigned authorizes the Northland Therapeutic Riding Center riding instructor, therapist, or executive director to seek any medical and/or surgical treatment necessary for the care of who is participating as a volunteer or rider in Northland Therapeutic Riding Center's program with parent/guardian permission (if under the age of 18). I understand that no liability can be accepted by any individual or organization concerned with this program in the event of any accident which may occur. Signature: Date: Choose appropriate title: Parent/Guardian Adult Volunteer Adult Rider Witness: Date: IF DECLINING MEDICAL TREATMENT, PLEASE SIGN BELOW I am declining medical treatment. Signature: Date: If declining medical treatment, please indicate what steps you want NTRC to take in case of an emergency: Close Window