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Volunteer Authorization for Emergency Medical Treatment Form by coreymcintyre

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									                Volunteer Authorization for Emergency Medical Treatment Form

In the event emergency medical aid/treatment is required due to illness or injury during the process of
volunteering, or while being on the property of Silver Buckle Youth Equestrian Center, I authorize
Silver Buckle Youth Equestrian Center to secure and retain medical treatment and transportation by
ambulance, if needed.
Volunteer’s Name: ______________________________________ SS#: ______________________
Address: ______________________________ City: _______________ State: _____ Zip: ________
In the event I cannot be reached, contact: _________________________ Phone: _______________
Emergency Contact:: _____________________________________ Phone: ___________________
Physician’s Name: _________________________________________________________________
Preferred Medical Facility: ___________________________________________________________
Health Insurance Co: ________________________________Policy #: ________________________

Consent Plan
This authorization includes x-rays, surge ry, hospitalization, medication and any treatment procedure
deemed “life saving” by the physician. This provision will only be invoked if the person above is
unable to be reached.
Date: __________ Consent Signature: ________________________________________________
                                         (Volunteer, Parent or Guardian)

Print Name: _________________________________________ Phone: ______________________
Address: ________________________________________________________________________

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 Silver Buckle Youth Equestrian
Center. In the event emergency treatment/aid is required, I wish the following procedures to take
place:
________________________________________________________________________________
________________________________________________________________________________
Date: ________________ Non-Consent Signature: _______________________________________
                                                                           (Volunteer, Parent or Guardian)

Print Name: ______________________________________ Phone: _________________________
Address: ________________________________________________________________________

								
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