Waiver to Print - Fill in completely and initial all spaces.
ACKNOWLEDGMENT of RISK and RELEASE of LIABILITY
WAIVER for those under 18 years old Please Print Clearly
WAIVER - PRINT, sign , intial and bring with you to your first lesson or send with your Camp or show entry.
Participant’s Name:
Date of Birth: Participant’s Address:
Guardian’s Name: Date of Birth:
Guardian’s Address: ______________________________________ City: ____________ Prov:_________________ Postal: __________________ Phone Number :_____________
Email :
The Participant and Guardian must Read and Understand prior to the Participant Participating in Equine ActivitiesTO: Catherine Colwell and Joseph McAllister _ their directors, employees, officers.
(Name of Person, Organization or Company providing the Equine Activities)
volunteers, business operators, and site property owners. (all of them collectively called the HOST)
Initial each item below After Reading and Understanding the item
_____1. I am the Parent and/or Legal Guardian of the infant Participant named above and am executing this form on behalf of the infant Participant in my capacity as parent and/or guardian and with the intent that this form be binding on myself and infant Participant for all legal purposes.
_____2. 1 Understand there are Inherent DANGERS, HAZARDS and RISKS, (collectively called RISKS) associated with Equine Activities and injuries resulting from these “RISKS” are a common occurrence.
_____3. I Acknowledge that the Inherent “RISKS” of Equine Activities mean those DANGEROUS conditions which are an integral part of Equine Activities, including but not limited to:
• The propensity of any equine to behave in ways that might result in injury, harm or death to persons on or around them and to potentially collide with, bite or kick other animals, people, or objects. • The unpredictability of an equine’s reaction to such things as sounds, sudden movement, tremors, vibrations. unfamiliar objects, persons or other animals and hazards such as subsurface objects • The potential for other participant (s) to act in a negligent manner that might contribute to injury to themselves or others, such as failing to act within their ability or to maintain control over an equine ___4. I Freely Accept and Fully Assume All Responsibility for the Inherent “RISKS” and the possibility of personal injury, death, property damage or loss which might result from the infant being a Participant
_____5. I Acknowledge that it remains my Sole Responsibility for the safety of the infant Participant and for the infant to Participate within his/her own limits.
____6. In addition to consideration given for the infant to Participate in Equine Activity, I and my heirs, executors, administrators and assigns (collectively called my “Legal Representatives”) agree • To Waive All Claims that I or the infant Participant might have against the “HOST”; and • To Release the “HOST” from Any and All Liability for any loss, damages, injury, or expense that I. the infant Participant or our “Legal Representatives” might suffer as a result of the infant’s Participation due to any cause including any NEGLIGENCE ON THE PART OF THE “HOST”: and
• To HOLD HARMLESS AND INDEMNIFY THE “HOST” from any and all liability for property damage or personal injury to the infant Participant or to any third party which might result from the infant’s Participation.
Before signing this form I read it (as indicated by my initials above) and I stated that I understand it. I further state I am aware that signing this form, waives certain legal rights I and/or the infant Participant and/or our “Legal Representatives” might have against the “HOST”.
SIGNED and initaled :
This ______________ day of_________________________2011.
Catherine Colwell and Joseph McAllister
(Print Name of HOST Witness to signing & Initialing)
_______________________________________(Signature of Participant) ( Do Not Sign until you Understand All Items Above ) .
________________________________
(Signature Host Witness) ____________________________________Please tell us about any learning or health issues that may be present in the student :
____________________________________________________________________________________________________
__________________________________________________
Any Allergies or health concerns: __________________________________________________
__________________________________________________
Please fill in any medical conditions that our instructors and helpers may need to be aware of.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Name of Emergency Contact:_______________________________________
Relationship to Student ___________________________________________
