Witness this agreement and authorization by and between Cedar Lane Stables, hereinafter referred to as “Management” and _________________________________, Hereinafter referred to as “Parent.”

Management is hereby authorized to obtain any and all medical treatment management deems necessary for minor child and/or children.
Parent or guardian agrees to bear any cost connected therewith and shall pay promptly upon billing by the healthcare provider. Management shall incur no financial liability for medical treatment obtained pursuant to this authorization.

            Name(s) of Child(ren)
___________________________
___________________________
___________________________

Health Insurance Carrier:____________________________________________________
Plan or Identification Number:________________________________________________
Primary Healthcare Provider and Phone Number:__________________________________

Parent’s names and emergency telephone numbers:










___________________________________________
Signature of Parent/ Guardian

State of (__________________________) County of (________________________)

The foregoing instrument was subscribed and sworn to me by
______________________________________________, Parent or Guardian,
on the __________ day of ___________________,__________.


____________________________________________________
NOTARY PUBLIC
My commission expires: _________________________________

Authorization to Obtain Medical Treatment for a Minor Child

 Social Security Number
____________________
____________________
____________________

Father's Name

Work Number

Home Number

Cell Number

Work Number

Home Number

Cell Number

Mother's Name

___________________________________________________________________

___________________________________________________________________