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Fill and Sign the Before Me a Notary Public in and for Said County Personally Appeared the above Named Form

Fill and Sign the Before Me a Notary Public in and for Said County Personally Appeared the above Named 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 Management 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 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 GuardianSTATE OF _______________________ COUNTY OF _____________________ Before me, a notary public in and for said county, personally appeared the above named __________________, who acknowledged that ________ (he/she) did sign the foregoing instrument, and that the same is his free act and deed. In testimony whereof, I have hereunto subscribed my name at _______________, this ____ day of ________________, ____. ____________________________________ Notary Public, State of _________________Printed Name:________________________ Commission Expires: __________________ © 2017 - Cottonwood Equestrian Publications

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