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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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