Triple H Ranch & Therapeutic Horsemanship

Emergency Contact Information

Please provide your contact details and emergency contact information for our records.

Your First Name

Your Last Name

Your Email Address

Your Phone Number

Medical conditions or allergies

Emergency Contacts

Please provide details for two people we can contact in case of an emergency.

1. Emergency contact name

Relationship to you

Emergency Contact Phone

2. Emergency contact name

Relationship to you

Emergency contact phone

Your Physician's Name

Your Physician's Phone Number

Hospital/Clinic and Location

This authorization includes x-rays, surgery, hospitalization, medication, and any treatment procedure deemed "life-saving" by the physician. This provision will only be invoked if your emergency contacts are unreachable.

I DO give my consent to Triple H Ranch & Therapeutic Horsemanship Foundation, Inc., for emergency medical treatment/aid & transportation in the case of illness or injury while being on the property of Triple H Ranch.

I DO NOT give my consent to Triple H Ranch & Therapeutic Horsemanship Foundation, Inc. for emergency medical treatment/aid & transportation in the case of illness or injury while being on the property of Triple H Ranch. If treatment/aid is required, I wish the following procedure to take place:

Please describe

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