Adult Registration and Release Form
Medicine Horse Center- P.O. Box 1074/40700 Road J, Mancos, CO 81328 call: 970-533-7403 email: info@medicinehorsecenter.org
Participant Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
In case of emergency contact:
Please enter a valid phone number.
Format: (000) 000-0000.
Photo Release
I hereby consent to and authorize the use and reproduction by Medicine Horse Center of any and all photographs and any other audiovisual materials taken of me/my ward for promotional printed and/or digital purposes (including social media and web site), educational activities or for any other use for the promotion of Medicine Horse Center and its programs.
Participant Authorization for Emergency Medical Treatment
In the event emergency medical aid/treatment is required due to illness or injury during the process ofreceiving services or while being on the property of the agency, I authorize Medicine Horse Center to: 1. Secure and retain medical treatment and transportation if needed. 2. Release participant records upon request to the authorized individual or agency involved in the medical emergency treatment at my expense. I hold Medicine Horse Center harmless for any expenses incurred in my interests.
Emergency Contact:
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Physician's name
First Name
Last Name
Physician's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Medical Facility
preferred facility in the event of emergency
Health Insurance Company and Number
Health Insurance Co.
Policy Number
Consent Plan
This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed “life saving” by the attending physician(s). This provision will only be invoked if the emergency contact person above is unable to be reached.
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 services or while being on the property of the agency.
In the event emergency treatment/aid is required, I wish the following procedure to take place:
Please add instructions here
Lastly, are there any known allergies or health concerns?
If none, just enter N/A
Continue
Continue
Should be Empty: