EMERGENCY MEDICAL RELEASE FORM

NOTICE TO ALL RIDERS, PARENTS & GUARDIANS:

To avoid unnecessary delay, it is recommended that you fill out and sign this form. For adult riders who are unresponsive or
unable to communicate properly, this form will be of value to your instructors and medical personnel.
For children, many situations have shown that a child can not receive emergency medical care without the authorization of a
parent or guardian.
Name of Rider: ____________________________________________________________
Address: Street: ___________________________________________________________
Town: ___________________________________________________________
State: ___________________________________________________________
Zip:
___________________________________________________________
Phone: Home: (
)______________________________________________________
Work: (
)______________________________________________________
Date of Birth: ______________________________________________________________
Person To Contact In Case Of Emergency: Name: _____________________________
Relationship to Rider:__________________
Phone: (
)_______________________
Medical Insurance Company___________________________________________________
Phone Number: _____________________________________________________________
Policy Number: _____________________________________________________________
Member Number:____________________________________________________________
Prior Medical History:
Pertinent Disease or Injury?____________________________________________________
Daily Medications?___________________________________________________________
Allergies:___________________________________________________________________
Contact Lens Wearer?_____________________________
Medical Doctors Name:__________________________ Phone: (
)_____________
Date of Last Tetanus Shot: _____________________________________________________
Other:______________________________________________________________________
RELEASE FOR AN ADULT RIDER (over 21 years of age):
If emergency medical care is required for myself and if I, or an accompanying spouse or relative, am not able to convey
permission in a timely manner, then the undersigned authorizes appropriate medical care as deemed necessary by emergency
medical personnel, a physician or the medical facility providing treatment.
I have read this entire release and agree to it:
Signed:___________________________________ Date: _________________________________

RELEASE FOR A MINOR RIDER: (under 21 years of age):

If emergency medical care is required for (Childs Name): ________________________________________
and if permission is not available in a timely manner, then the undersigned authorizes appropriate emergency medical care as
deemed necessary by emergency medical personnel, a physician, or the medical facility providing treatment.
I have read this entire release and agree to it:
Signature (of Parent or Gaurdian) _____________________________ Date:__________________________
Relationship to Rider________________________________________________________________________