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:
*
Parent/Guardian Full Name:
*
First Name
Last Name
Relationship to Participant:
*
Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number:
*
Please enter a valid phone number.
Secondary Phone Number:
Please enter a valid phone number.
Parent/Guardian Email Address:
*
example@example.com
Emergency Contact Information
Primary Emergency Contact Name (if different than the parent listed above):
First Name
Last Name
Relationship to Participant:
Phone Number (Mobile):
Please enter a valid phone number.
Phone Number (Secondary):
Please enter a valid phone number.
Secondary Emergency Contact Name (Optional):
First Name
Last Name
Relationship to Participant:
Phone Number (Mobile):
Please enter a valid phone number.
Phone Number (Secondary):
Please enter a valid phone number.
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 (Optional)
Physician's Name & Phone Number:
Health Insurance Provider & Policy Number:
Authorization for Emergency Medical Treatment
By signing below, I authorize AMP Stables & Boarding - B2 Services Inc and its staff to obtain emergency medical treatment for the minor participant named above in the event of an injury or medical emergency. I understand that I am responsible for all costs associated with such treatment.
Acknowledgment and Consent
I certify that the information provided in this form is accurate and complete to the best of my knowledge. I understand that this information will only be used in the event of an emergency and will be stored securely.
Parent/Guardian Signature:
*
Date
*
-
Month
-
Day
Year
Date
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Should be Empty: