Emergency Medical Release Form
Notice to All Riders Notice to Parents and Guardians
To avoid any unnecessary delay, the USEA recommends that In many situations, a minor child cannot receive emergency
you fill out and sign this form. You should make arrangements medical care without the authorization of a parent or guardian.
with a responsible person accompanying you to have this form If you are not going to be present personally at the horse trials,
available to medical personnel. you should consider using this form in conjunction with your
Name: child’s entry. You should make arrangements for a responsible
Soc. Sec. #: person accompanying your child to have this form available to
Date of Birth: medical personnel if required.
State: Zip: Release for an Adult Rider
If emergency medical care is required for myself and if I, or an
accompanying spouse or relative, am not able to convey per-
Person to Contact in Case of Emergency mission in a timely manner, then the undersigned authorizes
appropriate emergency medical care as deemed necessary by
Name: emergency medical personnel, a physician or the medical facil-
Telephone: ity providing treatment.
Medical Insurance Company: I have read this entire release and agree to it:
Member #: Signature:
Release for a Minor Rider
Prior Medical History:
If emergency medical care is required for:
and if permission is not available in a timely manner, then the
Allergies: undersigned authorizes appropriate emergency medical care
as deemed necessary by emergency medical personnel, a
Contact Lenses: physician or the medical facility providing treatment.
Telephone: I have read this entire release and agree to it:
Date of Last Tetanus Shot:
(parent or guardian)