Waiver to Print - Fill in completely and initial all spaces. ACKNOWLEDGMENT of RISK and RELEASE of LIABILITY WAIVER for those under 18 years old
Participant’s Name: Date of Birth: Participant’s Address: Guardian’s Name: Year of Birth: Guardian’s Address: Phone# : Email :
The Participant and
Guardian must Read and Understand prior to the Participant Participating in
Equine Activities
TO: 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 initialed : This
______________ day of_________________201__.
Catherine Colwell
and Joseph McAllister _______________________ ( Name of HOST Witness to signing) (Signature Host Witness) _____________________
______________________________________
(Signature of Guardian of Participant)
( Do
Not Sign until you Understand All Items Above )
Please tell us about any learning or health issues that may be present in the student : ____________________________________________________
IF needed please fill out a medical release form.
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: __________________ Cell#
Relationship to Student