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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 FLORIDACOUNTY OF _____________________ The foregoing instrument was acknowledged before me this ________________ (date), by __________________________________________ (name), who is personally known to me or who has produced ____________________________ (type of identification) as identification. ______________________________Notary PublicPrinted Name:__________________ My Commission Expires: © 2017 - Cottonwood Equestrian Publications____________________Commission #_________

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