HORSEMANIA   CAMP

www.horsemaniacamp.com

COYOTE RUN ARENA

MASON, TN

901-634-7484

MEDICAL AUTHORIZATION

Child's Name           ____________________________________________________________________________

Address                   ____________________________________________________________________________ ____________________________________________________________________________

Phone              _____________________________________________________________________________

Birth Date                _____________________________________________________________________________

Please complete the following information and submit any additional information that applies to your child.

Current Medications     _____________________________________________________________

Known Allergies           ______________________________________________________________

Does your child have any medical problems that we should be aware of?

_______No known medical conditions

_______Yes,   Please explain

_______________________________________________________________________________

_______________________________________________________________________________

Physician ________________________________________________________________________

Hospital _________________________________________________________________________

Insurance ________________________________________________________________________

Name on Policy ___________________________________________________________________

Policy or ID # _____________________________________________________________________

I give Horsemania Camp permission to treat my child in case of an emergency.

Parent or Guardian Signature __________________________________________________________

Date: ______________________

 
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