Fill and Sign the Me Personally Appeared Name of Person Form

© 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 VERMONT COUNTY OF _________________ On this _________ day of ____________________________, _______________, before me personally appeared ____________________________________________ (name of person acknowledging) to me known to be the person who executed the foregoing instrument, and _____________________________ he/she/they thereupon duly acknowledged to me that _____________ he/she/they executed the same to be _______ his/her/their free act and deed. ______________________________ Notary Public Print Name: ___________________ © 2017 - Cottonwood Equestrian Publications My commission expires: _____________________