Fill and Sign the On This Day Personally Appeared Before Me to Me 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 WASHINGTON COUNTY OF _____________ On this day personally appeared before me ______________________________, to me known to be the individual(s) described in and who executed the within and foregoing instrument, and acknowledged that he/she/they signed the same as his/her/their free and voluntary act and deed, for the uses and purposes therein mentioned. Given under my hand and seal of office this _______ day of _________________, 20______. ______________________________ © 2017 - Cottonwood Equestrian Publications Notary Public residing at _________ Printed Name: _________________ My Commission Expires: _____________________