Oakwood Farm Summer Camp Medical Form

RIDER Name*

First NameLast Name

Medical Insurance Carrier and Policy #:*

Allergies:*

**Allergens, including but not limited to natural and man-made origin, are included as inherent risks assumed wile participating in any activity on the property, including but not limited to horse riding, grooming or observing activities. Oakwood Sport Horses LLC does not and cannot control the food items brought onto the premises during any and all activities, including during camps and clinics. Oakwood Farm, its employees and its volunteers are not trained to respond to any medical emergency including those caused by an allergic reaction. Oakwood Sport Horses LLC, its employees and its volunteers cannot administer medication, including inhalers or Epi-pens, for those riders who may need them. Should an emergency situation arise, 911 will be called and the rider will be made as comfortable as possible while waiting for first responders to arrive, unless otherwise directed by camper’s parent(s)/guardian(s). I understand that Oakwood Sport Horses LLC or any related parties are not responsible or liable for any allergic reaction that may occur while the rider is on the property.initials* (Initials)

Special Needs/Conditions/Disabilities:*

Daily Medication (if applicable, please describe):*

Emergency Contact Name and Telephone:*

CONSENT PLAN:
This authorization includes x-ray, surgery, hospitalizations, medication and any treatment procedure deemed “life-saving” by the physical. This provision will only be invoked if the person below is unable to be reached within a critical time period.
Signature  Consent Signature
Name  Print Name
Phone Phone
Address  Address

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 service, volunteering, or while being on the property of the agency. In the event emergency aid/treatment is required, I wish the following procedures to take place (If you choose this plan, you must fill in some specifics for the aid which you will/will not allow):
Aid Specifics you will/will not allow:

Signature  Consent Signature
Name  Print Name
Phone Phone
Address  Address