Fill and Sign the Alternative Horsemanship with Samantha Harvey Clinic Registration Form

© 2017 - Cottonwood Equestrian Publications AUTHORIZATION TO OBTAIN MEDICAL TREATMENT FOR MINOR CHILD WITNESS THIS AGREEMENT AND AUTHORIZATION by and between F ARM NAME, hereinafter referred to as "Management," and ________________________________, hereinafter referred to as "Parent." Management is hereby authorized to obtain any and all medical treatme nt Management deems reasonably necessary for my minor child and/or children. Parent or guardian agrees to bear any cost connected therewith and shall pa y promptly upon billing by the health care provider. Management shall incur no financia l liability 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 MARYLAND COUNTY OF ________________ Personally appeared before me, a Notary Public, in and for said county and state, on this ________ day of __________________, 20____, the within named ________________________________, known to me, or satisfactorily proven, to be the person whose name is subscribed to the within instrument and who acknowledges that he/she/they (strike one) executed the same for the purposes therein contained. ______________________________ NOTARY PUBLIC Print Name: ___________________ © 2017 - Cottonwood Equestrian Publications My Commission Expires: _____________________