Volunteer & Participant Liability Release Form Volunteer Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Cell Phone * (###) ### #### Home Phone (###) ### #### Work Phone (###) ### #### Email * Emergency Contact Name * First Name Last Name Relation Emergency Contact Phone * (###) ### #### Medical Consent to Treat/Medical Consent to NOT Treat * I AUTHORIZE CDHR to secure and authorize such emergency medical treatment as stated above. I DO NOT AUTHORIZE CDHR to secure and authorize such emergency medical treatment as stated above. Connecticut Equine Activity Statute ELECTRONIC SIGNATURE ACKNOWLEDGEMENT AND CONSENT FORM I, , agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement. First Name Last Name Date MM DD YYYY Guardian Consent Name First Name Last Name Date MM DD YYYY Thank you and welcome to the team! If you have any questions, please do not hesitate to reach out to us. Sign up with your email address to receive news and updates. First Name Last Name Email Address Sign Up Thank you!
