Indian Ocean Reining WPH- Medical Form

Medical Form

Confidential Riding Application and Medical History Form
Name

First NameLast Name
Phone Number

Area CodePhone Number
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
In Case of Emergency
Name

First NameLast Name
Phone

Area CodePhone Number
Name

First NameLast Name
Phone

Area CodePhone Number
Riding experience. The number of times the rider has ridden in the last 12 months.
I agree to the following:
General Medical History
Tetanus ImmunisationIt is particularly important that people dealing with horses are immunised against tetanus. Tetanus is normally given at five years of age as Triple antigen or CDT and at fifteen years of age as ADT.
Date of Last Tetanus or Diptheria, Tetanus, Pertussis(DTaP) Vaccine?

MonthDayYear
Date
Does you or your child have any food, medication or environmental allergies?
Allergies please describe allergy and or reaction. What action is needed for your allergy?
If you need an EPI-PEN you need to bring your own.
Check all that apply
If yes to any please provide more information.
Is any medication required?
List any medication taken regularly:
Is it necessary for you or your child to carry their own medication at all times? if so Name of drug, frequency and dosage.
In the event that the child care program must be evacuated, are there medications or supplies that must be taken with this child
Are you a St johns member or have ambulance cover with your private health?
If you do not have ambulance cover it is recommened that you obtian.

I authorize the club committee in charge to administer first aid and call an ambulance.

I agree to any cost that are incurred.
Are there any learning difficulties that need to be discussed, so the Instructors/Guides are able to accommodate accordingly? Please describe:
Consent To Medical Attention
Should be Empty:

Medical Form

In Case of Emergency

General Medical History