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Fill and Sign the Being First Sworn under Oath States that Heshe Signed the above Form

Fill and Sign the Being First Sworn under Oath States that Heshe Signed the above Form

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© 2017 - Cottonwood Equestrian Publications AUTHORIZATION TO OBTAIN MEDICAL TREATMENT FOR MINOR CHILD WITNESS THIS AGREEMENT AND AUTHORIZATION by and between FARM NAME, hereinafter referred to as "Management," and ________________________________, hereinafter referred to as "Parent." Management is hereby authorized to obtain any and all medical treatment Mana gement deems reasonably necessary for my minor child and/or children. Parent or guardian agrees to bear any cost connected therewith and shall pay promptly upon billing by the health care provider. Management shall incur no financial liabil ity for medical treatment obtained pursuant to this authorization. Name(s) of child(ren) Social Security No. Health Insurance Carrier: Plan or Identification No. Primary Healthcare Provider Signature of Parent or Guardian STATE OF OKLAHOMA COUNTY OF ________________ ___________________, being first sworn under oath, states that he/she signed the above application and that the statements therein are true to the best of his/her knowledge and belief. _________________________________ Signature Subscribed and sworn to before me this ______ day of ________________________, 19____. _________________________________ NOTARY PUBLIC My Commission Expires: ________________ © 2017 - Cottonwood Equestrian Publications

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