Authorization for Emergency Medical Treatment

Authorization for Emergency Medical Treatment

This form grants permission for Shoulder to Shoulder Ranch staff to seek and authorize emergency medical care for a participant if a parent, guardian, or listed emergency contact cannot be reached. It ensures that medical professionals have the information and consent needed to provide timely treatment in the event of an illness, injury, or medical emergency while the participant is attending ranch programs. Completing this form helps us care for participants safely and respond quickly if a medical situation arises.

I am a
Name(Required)
Address
Email(Required)
Emergency Contacts
Name
Name
Name
1. Secure and retain medical treatment and transportation. 2. Release client records upon request to the authorized individual or agency involved in the medical treatment.
Consent Signature
MM slash DD slash YYYY
Consent Signature
MM slash DD slash YYYY