Hooves to Heal, NFP, 20604 Collins Rd., Marengo, Illinois, 60152

Patty Mozal ~ 847-293-6176

Authorization for Emergency Medical Treatment Form

Name:___________________________________________ DOB:____________ Phone:____________________

Address:____________________________________________________________________________________

Nature of disability:____________________________________________________________________________

Physician’s Name:__________________________________________ Phone:_____________________________

Preferred Medical Facility:_______________________________________________________________________

Health Insurance Co:______________________________________________ Policy #:_____________________

Allergies to Medication:_________________________________________________________________________

Current Medications:___________________________________________________________________________

Date of last Tetanus Shot:_____________________________________

The rider is currently independently covered by his or her own accident/medical insurance

and will remain insured for the duration of all programs at Hooves to Heal, NFP.	___________
	Initials
In the event of an emergency, contact:

Name:_______________________________________ Relation:__________________ Phone:________________

Name:_______________________________________ Relation:__________________ Phone:________________

Name:_______________________________________ Relation:__________________ Phone:________________

In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the property of the agency, I authorize Hooves to Heal, NFP to:

1.Secure and retain medical treatment and transportation if needed.

2.Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.

Consent Plan

This authorization includes x-rays, surgery, hospitalization, medication and any treatment procedure deemed “life saving” by the physician. This provision will only be invoked if the person(s) above are unable to be reached.

Date:_____________________ Consent Signature:__________________________________________________

Participant, Parent or Legal Guardian Signed in presence of center staff

Non-Consent Plan

I do NOT give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency. A parent or legal guardian will remain on site at all times during equine assisted activities.

In the event emergency treatment/aid is required, I wish the following procedures to take place:

___________________________________________________________________________________

___________________________________________________________________________________

I understand and agree that under no circumstances shall Hooves to Heal, NFP, their respective members, Board of Directors, managers, directors, agents, instructors, employees, therapists, property owners, and horse owners be liable for any damages, injury, or other loss, resulting from or in connection with the provision of such care.

Date:_____________________ Consent Signature:____________________________________________

Participant, Parent or Legal Guardian Signed in presence of center staff

∼ Participant ∼ Staff ∼ Volunteer∼