Dreams Go On
3085 Scotch Valley Road
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:
______________________________________________________
Page 1 of 1 2/2009