Reins From Above Therapeutic Riding Center, Inc.
841 Wiggins Rd. 
Angier, NC 27501
Phone: 919-631-9294
Website: www.reinsfromabove.org

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT FORM
Check one: ___Participant ___Volunteer ___Staff
Date:_________________________  Email Address:________________________________________________________________
Name (of Participant, Volunteer or Staff Member):_________________________________________________Date of Birth:________ Address:____________________________________________________________________Phone:__________________________ Preferred Medical Facility_______________________________________________________________________________________ Physician’s Name:________________________________________________Phone:_______________________________________ Health Insurance Co.:____________________________________________ Policy #_______________________________________ Emergency Contacts: Name:______________________________________________Relation:______________Phone:_____________________________ Name:______________________________________________Relation:______________Phone:_____________________________ Allergies to Medications:________________________________________________________________________________________ Current Medications:___________________________________________________________________________________________
In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving 
services, volunteering, or while being on the property of the agency, I hereby authorize Reins From Above Therapeutic Riding Center, Inc. to: 
1.	Secure and retain medical treatment and transportation if needed. 
2.	Release client or volunteer records upon request to the authorized individual or agency involved in the emergency medical treatment. 

CONSENT PLAN (Parents/legal guardians must sign for children under 18 or for wards of the court) 
This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed “life-saving” by the physician.  This provision will only be invoked if the person below is unable to be reached. 
Date:________________ Consent Signature:_______________________________________________________________________ 
Print Name:__________________________________________________________________________________________________ Phone:__________________________ Address:____________________________________________________________________ 
NON-CONSENT PLAN 
I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services, volunteering, or while being on the property of the agency. In the event emergency aid/treatment is required, I wish the following procedures to take place (If you choose this plan, you must fill in some specifics for the aid which you will/will not allow): 
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Date:______________ Non-Consent Signature:_____________________________________________________________________
Print Name:__________________________________________________________________________________________________
Phone:__________________________Address:_____________________________________________________________________
A copy of the completed Medical Form or Health History should be attached to this form.