Emergency Contact and Medical Information Form
Please complete one emergency contact and medical information form for each participating child.
Participant Information
Child’s Full Name:
*
First Name
Last Name
Date of Birth:
*
Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Information
Primary Emergency Contact Name:
*
First Name
Last Name
Relationship to Participant:
*
Phone Number (Mobile):
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number (Secondary):
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Secondary Emergency Contact Name (Optional):
First Name
Last Name
Relationship to Participant:
Phone Number (Mobile):
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number (Secondary):
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Medical Information (if applicable):
Known Allergies or "None" (e.g., food, medications, insect stings):
*
Current Medications or "None" (Name and Dosage):
*
Medical Conditions or "None" (e.g., asthma, diabetes, epilepsy, etc.):
*
Physical Limitations or Restrictions or "None" (e.g., difficulty mounting/dismounting, recent injuries):
*
Special Instructions (Any other information that you would like to provide. If you are providing any additional emergency contacts, please make sure to provide their full name, phone number and relationship.)
Physician's Name & Phone Number:
Health Insurance Provider & Policy Number:
Emergency Medical Authorization & Temporary Supervision Consent
By signing below, I authorize AMP Stables & Boarding – B2 Services Inc, including its staff, instructors, contractors, and volunteers, to obtain emergency medical care, evaluation, transportation, or treatment for the minor participant named above in the event of illness, injury, or medical emergency. I understand that if I or my listed emergency contacts cannot be reached, medical decisions may be made by EMS personnel, medical providers, urgent care, or hospital staff, and I agree that I am financially responsible for all costs associated with such treatment. I further authorize my child to remain on the premises under appropriate supervision while reasonable efforts are made to contact me or my listed emergency contacts.
Acknowledgment and Consent
By signing below, I certify that the information provided in this form is accurate and complete to the best of my knowledge. I understand that this information is used solely for participant safety and emergency response, will be stored securely, and will not be shared publicly. I agree to notify AMP Stables & Boarding if any medical or safety information changes during the year.
Parent/Guardian Signature:
*
Date
*
-
Month
-
Day
Year
Date
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Should be Empty: