Classical Equus Royal Vaulters

MEDICAL INFORMATION AND TREATMENT RELEASE

If medical care is required for _____________________________________________________ (name of CERV Member) in conjunction with any CERV activity or related transportation, and if normal permission is not available in a timely manner, the undersigned authorizes appropriate medical care as deemed necessary by emergency medical personnel, a physician, or the medical facility providing treatment.

Dated:_______________ Signed:________________________________

___________________________________

(Printed Name of Signor)

RELATED INFORMATION

Parent or Guardian:_____________________________________________________________

Address: _____________________________________________________________________

City/State/Zip:_________________________________________________________________

Home phone: (_____)_____________________ Work phone: (_____)_____________________
Cell phone: (_____) ______________________

If Parent or Guardian is unavailable,

Contact: _________________________________________Phone:(_____)_________________

Family Physician: ___________________________________Phone: (_____)_______________

My child is allergic to:____________________________________________________________ ______________________________________________________________________________

Other medical conditions:_________________________________________________________ _____________________________________________________________________________

My child takes the following medication(s): __________________________________________ ______________________________________________________________________________
for: __________________________________________________________________________

Child’s date of birth (month, day, year):__________________

Medical Insurance Company: ____________________________________________________

Policy Number(s): _____________________________________________________________ ____________________________________________________________________________

SPECIAL INSTRUCTIONS

As parent or guardian of the above named child, please attempt to contact me at the time of the accident or illness without postponing medical treatment.

Other: _______________________________________________________________________________________

I HAVE READ THIS ENTIRE RELEASE AND AGREE TO IT:

______________________________________(Participant) Date_____________
______________________________________(Legal Guardian) Date_____________

Original Signature of CERV Member and Original Signature of Parent(s) or Legal Guardian (if not 18 yr. or older)

OTHER INSTRUCTIONS FOR TREATMENT RELEASE

Organizers and DCs must retain this form (with original signatures) on file. Various officials may hold copies, for example: medical personnel on site, instructors, test examiners and chaperones.

REPORT OF EXISTING MEDICAL CONDITION(S)

Does the above named CERV member have any medical condition(s) that may be affected by mounted or unmounted participation in CERV activities? ___Yes ___No.

If you answered Yes above, complete section 2.

Section 2: MEDICAL RELEASE FOR ACTIVITY PARTICIPATION FOR MEMBERS WITH A MEDICAL CONDITION

Member Name:_________________________________________________________________________

CERV wishes to take reasonable steps to maintain the safety of CERV members. Members with medical /disabilities conditions (including pregnancy) that may be aggravated by mounted or unmounted activities must provide a MEDICAL RELEASE FOR PARTICIPATION Form signed by the examining physician. A copy of this form must be on file with the Club.

CERV leaders and instructors always have the sole discretion to remove any individual from an activity if safety is a concern.

This notice must be given at least 15 days prior to participation.

The responsibility for notice of a medical condition/disability and providing the completed release in a timely manner lies solely with the CERV member, parents, and/or legal guardian. The parents are also responsible for updating this release if the medical condition changes. CERV leaders are not required to seek out members and inquire about medical conditions.

PENALTY

The failure to provide the CERV leaders with information regarding a member’s medical condition/disability and to comply with the guidelines for notice, medical participation release, and consent requirements shall require that the member be disqualified from participation in CERV activities, and shall be a material misrepresentation that the CERV member has no medical condition/disability which might affect his/her participation.

EXAMINING PHYSICIAN’S RELEASE

Physician’s Name: ________________________________________________

Office Phone: ___________________________

Address: ____________________________________________________________________

City/State/Zip: _______________________________________________________________

Licensure No._________________________________ State of:________________________

The above named member has been seen by me on (date):_____________________________

I hereby release the above named CERV member to participate in mounted and unmounted equine activities. I am familiar with all of the requirements of CERV mounted and unmounted events. If I believe the member may participate in some of the events, but not in others, I will list them below.

Medical Condition:______________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Limitations: (use additional page if necessary to explain) ____________________________________________________________________________
____________________________________________________________________________
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Physician’s Signature: __________________________________________________________________

Date:____________________________