Medical & Emergency

Winslow Therapeutic Riding Center
1433 State Route 17A Warwick, NY 10990
Phone: (845) 986-6686

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* Today's Date

Date

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* Contact Information

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* If under 18 years of age, please provide contact information for Parent/Legal Guardian

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* Health History (please describe your current health status, specifically regarding the physical and emotional demands of working in a therapeutic riding program. Address fitness, cardiac, respiratory, bone or joint functions, recent hospitalizations or surgeries, and mental and emotional stability.

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* Allergies

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* Daily Medications & Their Purpose

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* Medical Information

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* Emergency Contact Information

Authorization for Emergency Medical Treatment

In the event emergency medial aid/treatment is required due to illness or injury during involvement with Winslow or while on the property of the organization, I authorize Winslow Therapeutic Center to:
a)      secure and retain medical and transportation if needed
b)     Release records upon request to the authorized individual or agency involved in the medical emergency treatment.
This authorization includes x-rays, surgery, hospitalization, medication and any treatment or procedure deemed “lifesaving” by the attending physicians.

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* Medical Treatment Authorization (by entering your full name as your legal signature below, you are legally bound to the contents and statements within this document)

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