Dreams Go On with High Hopes
Therapeutic Horseback Riding Program
RR 2 Box 351
Hollidaysburg, PA 16648
CONSENT FOR RELEASE OF INFORMATION
I hereby authorize______________________________(person or agency) to release information from the records of ______________________________(rider) to Dreams Go On, for the purpose of developing goals and objectives for a therapeutic horseback riding program. The information to be released is marked below.
__________ Medical History
__________ Physical Therapy evaluation and assessment
__________ Occupational Therapy evaluation and assessment
__________ Speech Therapy evaluation and assessment
__________ Classroom Individual Education Plan
__________ Other: _______________________________________
Signature of Parent or Guardian: ________________________________________
Date: ____________________________
In the event emergency/medical treatment is required due to illness or injury during a riding session or while on the property, I authorize Dreams Go On, Inc. Staff to provide the appropriate basic medical treatment.
Parent or Guardian:
______________________________________________________
Please send the indicated material to: Dreams Go On RR 2 Box 351 Hollidaysburg, PA 16648 OR Debbie Kelly, Rider Coordinator 1006 Valley View Blvd
Altoona, PA 16602
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