Spring
Break Camp 2010 Registration Form
PLEASE READ CAREFULLY BEFORE SIGNING
Serious
injuries may result from participation in this activity.
April 5-9 2010
9:00 AM – 4:00 PM
$395.00
A. Registration
of Riders and Agreement Purpose: In consideration of the applicable fee and
the signing of this agreement, I, the following listed individual, or the
parent or legal guardian thereof a minor, do hereby voluntarily request and
agree to participate in riding instruction as a student of Columbia Horse
Center, and that this student will either ride his/her own horse, or school
horse provided by Columbia Horse Center/Columbia Association for instructional
purpose. I understand that I am
responsible for the entire payment of my series.
Student’s Name _________________________________________________________________________________
Street Address __________________________________________________________________________________
City, State, Zip__________________________________________________________________________________
Age _________________ Birth
date _________________ Telephone Number (Home) ___________________
(Work) Referred by ________________________________________________________
(Please Complete - Yellow Pages, Internet,
Newspaper, Friend, Sign)
Email Address
__________________________________________________________________________________
(Please Print Clearly)
In Case of Emergency Call:
_______________________________________________________________________
(Name) (Telephone Number)
Please Circle Riding Experience: None Walk Trot Canter Jump
Does the rider have any physical and/or mental health
conditions, problems, and/or disorders which may affect his/her safety and
ability to ride a horse? Yes No If
“yes” describe here:
B. Agreement and Territory and
Definitions: This agreement shall be legally binding upon me the registered
student, and the parents or legal guardian thereof if a minor, my heirs,
estate, assigns, including all minor children, and personal representative; and
it shall be interpreted according to the laws of the State of Maryland and the
county of Howard. Any disputes by the
rider shall be litigated in, and venue shall be
C. Activity
Risk Classification: I UNDERSTAND THAT: Horseback riding is classified as
RUGGED ADVENTURE RECREATIONAL SPORT ACTIVITY, and that there are numerous
obvious and non-obvious inherent risks always present in such activity despite
all safety precautions. According to NEISS (National Electronic Injury
Surveillance Systems of
D. Nature of School Horses: I
UNDERSTAND THAT: Columbia Horse Center/Columbia Association chooses its school
horses for their calm disposition and sound basic training as is required for
use for student riders, and Columbia Horse Center/Columbia Association follows
a rigid safety program. Yet, no riding
horse is a completely safe horse. Horses
are 5 to 15 times larger, 20 to 40 times more powerful, and 3 to 4 times faster
than a human. If a rider falls from a horse to ground it will generally be a
distance of from 3 ½ to 5 ½ feet, and the impact may result in injury to the
rider. Horseback riding is the only
sport where one much smaller, weaker predator animal (human) tries to impose
its will on, and become one unit of movement with, another much larger,
stronger prey animal with a mind of its own (horse) and each as a limited
understanding of the other. If a horse if frightened or provoked it may divert
from its training and act according to its natural survival instincts which may
include, but are not limited to: Stopping short, Changing directions or speed
at will, Shifting its weight, Bucking, Rearing, Kicking, Biting, or Running
from danger.
E. Rider
Responsibility: I UNDERSTAND THAT: Upon mounting a
horse and taking up the reins, the rider is in primary control of the horse.
The rider’s safety largely depends upon his/her ability to carry out simple
instructions and his/her ability to remain balanced aboard the moving animal. I
agree that the rider shall be responsible for his/her own safety, including
that of an unborn child, if the rider is pregnant. Columbia Horse Center/Columbia Association
advises pregnant women not to ride horses.
F. Conditions
of Nature and Inspection of Premises: I UNDERSTAND THAT: Columbia Horse
Center/Columbia Association is NOT responsible for total or partial acts,
occurrences, or elements of nature that can scare a horse, cause it to full, or
react in some other unsafe way. Some examples are: Thunder, lightening, rain,
wind, wild or domestic animals, insects, reptiles, which may walk, run, or fly
near, or bite or sting a horse or person; and irregular footing on out of door
groomed or wild land which is subject to constant change in condition according
to weather, temperature, and natural and man-made changes in landscape. The
rider or parent or legal guardian have
inspected Columbia Horse Center/Columbia Association facilities, as have the Howard
County inspections, as per our stable license, and are satisfied that all
premise conditions are reasonable safe for rider’s intended purpose, usage, and
presence upon Columbia Horse Center/Columbia Association’s premises.
G. Saddles
Girth/Natural Loosening: I UNDERSTAND THAT: Saddle girth (saddle fasteners
around the horse’s belly) may loosen during a ride. If a rider notices this, he/she must alert
the riding instructor as quickly as possible so action can be taken to avoid
slippage of saddle and a potential fall from the animal.
H. Accident/Medical
Insurance: I AGREE THAT: Should emergency medical treatment be required, I
and/or my own accident/medical insurance company shall pay for all such
incurred expenses.
I. Protective
Headgear Warning: I AGREE THAT: I shall purchase and wear protective
headgear (approved equestrian riding helmet) while around and mounted on the
animals. I understand that the wearing of such headgear while mounting, riding,
dismounting, and otherwise being around horses, may prevent or reduce severity
of some head injuries, and may even prevent death from happening as the result
of all or other occurrence, but cannot guarantee my safety or that of my
child.
J. Liability
Release: I AGREE THAT: In consideration of Columbia Horse Center/Columbia
Association allowing my participation in this activity, under the terms set
forth herein, I , the rider, and the parent or guardian thereof if a minor, do
agree to hold harmless and release Columbia Horse Center/Columbia Association,
its owners, agents, employees, officers, members, students, premises owners,
affiliated organizations and insurers from legal liability due to Columbia
Horse Center/Columbia Association’s ordinary negligence; and I do further agree
that except in the event of Columbia Horse Center/Columbia Association’s gross
and willful negligence, I shall bring no claims, demands, actions and causes of
actions, and/or litigation, against Columbia Horse Center/Columbia Association
and its associates as stated above in this clause, for any economic and
non-economic losses due to bodily injury, death, property damage, sustained by
me and/or my minor child or legal ward in relation to the premises and
operations of Columbia Horse Center/Columbia Association, to include while
riding, handling, or otherwise being near horses owned by or in the care,
custody and control of Columbia Horse Center/Columbia Association.
All Riders and Parents or Legal Guardians
Must Sign Below After Reading This Entire Document:
________________________________________________________________________________________________________________________
SIGNER STATEMENT OF AWARENESS
I/We, the undersigned, have read and do
understand the foregoing agreement, warnings, release and assumption of
risk. I/We further attest that all facts
relating to the applicant’s physical condition, experience, and age are true
and accurate.
Signature of Rider
_______________________________________________________ Date
________________________
Signature of Parent or
Guardian _____________________________________________ Date
________________________
Printed
Name_______________________________________________________________________
TO BE COMPLETED BY CHC:
Cost of
Cost of B/A Care Due (if applicable): $55.00 (please circle if your child will be part
of the B/A Care Program)
Total Amount Due:
____________________________________________________________
Deposit Received/Check # or CC type:
____________________________________________