I understand that I am responsible for any costs associated with these activities or field trips unless otherwise agreed upon by Tri-Cities Horsemen's Association and/or Tri-Cities Junior Horsemen's Association.

I hereby give permission for my child to receive emergency medical, dental, or surgical treatment, and to be hospitalized if necessary. It is understood that every attempt will be made to contact me or the person below before taking this action. I understand that I am responsible for any and all costs incurred in seeking medical treatment.

Signed by Parent/Guardian:____________________________________Date:___________________

Address_____________________________________________________________________________

Day Phone/Cell:_________________________________Evening:_____________________________

Or in case of Emergency, please call_____________________________________________________

Address_____________________________________________________________________________

Day Phone/Cell:_________________________________Evening:_____________________________

Please note any special medical conditions or allergies to medication. If none please state NONE:

___________________________________________________________________________________

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