PONY PAL SUMMER CAMP 2009
RELEASE FORM
PLEASE READ CAREFULLY BEFORE SIGNING
Serious injuries may result from participation in this activity.
Session 1:
June 22 Session
6: July 27
Session 2: June 29 Session
7: August 3
Session
3: July 6 Session 8: August 10
Session
4: July 13 Session 9: August 17 (½ day
9:00-12:30)
Session 5 July 20
___________________________________________________________________________________________________________
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/Columbia Association, 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 Phone
__________________ E-Mail
Address________________________________________________
(Please Print Clearly)
Referred by:
_________________________________________________________________________________
(Please Complete: Yellow Pages, Friend, Sign,
Newspaper, Internet)
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
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 United States Consumer Products) horse activities rank
64th among the activities of people relative to injuries that result in a stay
at
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
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): $60.00 (please circle if your child will be part of
the B/A Care Program)
Total Amount Due:
____________________________________________________________
Deposit Received/Check # or CC type:
____________________________________________
Balance Due by one week prior to start of camp: ____________________________________