United States Mounted Games Association
If medical care is required for____________________________ in conjunction with any USMGA activity or related transportation, and if normal permission is not available in timely manner, the undersigned authorizes appropriate medical care as deemed necessary by emergency medical personnel, a physician, or the medical facility providing treatment.
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RELATED INFORMATION: |
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Parent or Guardian:______________________________________________ |
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Address: __________________________________________________________________________ |
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Telephone: |
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Home:____________________ Cell: ______________________ Work: _______________________ |
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If parent and Guardian is unavailable: |
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Contact:______________________________________________ Phone: ______________________ |
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Family Physician: _____________________________________ Phone: ______________________ |
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My child is allergic to: _________________________________ |
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Other medical conditions: ______________________________ |
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My child takes the following medications: _____________________________________________ |
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_____________________for____________________________________________________________ |
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Child's Date of Birth (month-day-year):_________________________________________ |
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Medical Insurance Company:_____________________________________________________________ |
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Policy Number(s): ______________________________________________________________________ |
SPECIAL INSTRUCTION
As parent or guardian of the above named child, please attempt to contact me at the time of the accident or illness without postponing medical treatment.
I HAVE READ THIS ENTIRE RELEASE AND AGREE TO IT:
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__________________________________________________ ____________________________ |
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Original Signature of Parent or Guardian Date |
OTHER INSTRUCTIONS:
We recommended that you check with your local emergency room for their information. Emergency rooms that require legal authority for treatment in the absence of the parents or guardians will be of assistance in helping you obtain necessary information.
