Fill and Sign the Plan or Identification No 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 _______________________ COUNTY OF _____________________ On this ____ day of __________________ , in the year ____ , before me personally appeared _______________________, known to me (or proved to me on the oath of _________________) to be the person who is described in and who executed the within and foregoing instrument, and acknowledged to me that _______ (he/she/they) executed the same. (Seal) ___________________________________ Notary Public, State of Printed Name:________________________ © 2017 - Cottonwood Equestrian Publications Commission Expires: _________________