Rider Information Online Form

Rider Information Online Application

You can print off and fill out this information prior to your lesson.  This will save time when you get to the farm! RIDER INFORMATION FORM NAME: ________________________________________ DATE: ____________________ ADDRESS: ________________________________________________________________ CITY: _________________________ZIP: _______E-MAIL: ________________________ PHONE: (_____)_____________________ WORK: (_____)_________________________ OTHER PHONE NUMBER: (_____)____________DATE OF BIRTH: _____/_____/_____ Do you have health insurance? Y/N What company? ________________________________ Contact in case of emergency (name + phone #): ___________________________________ Medical concerns/conditions:___________________________________________________     RIDING EXPERIENCE: How long have you been riding? _____Level of riding: Beginner/ Intermediate/ Advanced Trail Rides Y / N Lessons Y / N - if yes please indicate level and discipline below: ENGLISH Y / N LEVEL: _______________________________ DRESSAGE Y / N LEVEL: _______________________________ EQUITATION Y / N LEVEL: _______________________________ HUNTER/ JUMPER Y / N LEVEL: _______________________________ WESTERN Y / N LEVEL: _______________________________   DO YOU OWN YOUR OWN EQUIPMENT? Tack (Saddle / Bridle) Y / N Other: ___________________________________________ Riding Apparel (Helmet/ Boots/ Chaps/ Breeches) Y / N Other: _______________________   *We require at least 48 hours notice of cancellation or we charge you the full amount (initial)_____     FOR INSTRUCTORS USE ONLY: Discipline desired to learn Lessons Camp Boarder TR

Horse and Rider Goals

HORSE GOALS   For my Horse _____________________________________________________________________________________________________________________   _________________________________________________________________________________________________________________________________   For Myself _________________________________________________________________________________________________________________________   _________________________________________________________________________________________________________________________________   Show Goals _____________________________________________________________________________________________________________________   _________________________________________________________________________________________________________________________________   Lesson Goals _______________________________________________________________________________________________________________________   _________________________________________________________________________________________________________________________________   How can I help someone else with their Goals? ______________________________________________________________________________________________________________________________________   Commitment Statement __________________________________________________________________________________________________________________     Signature ________________________________________________________

RELEASE LIABILITY

Date ___________ Instructor ____________________ Did you trailer in? ________

Please carefully read and initial each paragraph as you approve it.

I, ______________________________, am fully aware and fully understand that all horses are unpredictable and dangerous. I realize that placing my children or myself in a stables environment is creating a hazardous situation. Initial ______

I understand that riding horses or ponies is a dangerous sport. I am aware that riders expect to be injured from time to time. I understand that death of people from equestrian accidents is possible. Initial ______

I understand that professional instruction cannot prevent serious injury or death from working around, handling, or riding horses or ponies. Initial ______

I understand that the jumping of horses or ponies is a particularly dangerous activity and that serious injury or death of riders or horses is possible. Initial ______

I am aware that serious injury or death of my mount is possible when it is handled, trained or in a lesson. Initial _______

I release ___________________________, its owners and employees, agents and independent trainers from all liability for damage to my property, injuries or death of children, animals or myself. Initial _______ '

______________________________, its owners and employees, and agents and independent trainers have my permission to initiate emergency first aid treatment for me, or my children, and my animals in case of an accident. They also have my permission to authorize emergency medical treatment by qualified medical personnel for me, or my children, and veterinarian treatment by qualified veterinarian personnel for my animals. Initial _______

I understand I am fully responsible for any guest I may have on the property. I understand I am fully responsible for fully informing the guest of all risks relating to handling or riding horses. I understand I am fully responsible for informing the guest about horse’s temperament, training, habits, and for determining that the guest is sufficiently experienced to ride the horse. Initial ________

I have carefully read each paragraph listed above and agree to its contents. I am over 21 years of age. Initial _________

Name (print) ____________________________ Signature _______________________

Name of Parent or Guardian (if signing for a minor) ___________________________

Signature (if signing for a minor) ____________________________________________

Address ________________________________________________________________

_______________________________________________________________________

Phone ________________________ Business Phone __________________________

Cell _________________________

Emergency contact _______________________ Emergency Phone # ________________

E-mail _________________________________

Child’s Name ___________________________ Age _______

Child’s Name ___________________________ Age _______

Child’s Name ___________________________ Age _______

Child’s Name ___________________________ Age _______

BARN RULES

We are closed on Mondays, exception is a holiday on a __________ closing at ______

Summer barn hours are: 7 am - 7pm . Sundays 8am  - 5pm

Winter barn hours are: 8am - 6pm  to dusk. Sundays 8am - 5pm

Speed limit is 5 miles per hour. Drive slowly and carefully.

Please park in the parking lot only. Our parking lot is the non paved area. Drop of and pick up only where posted.

Wear proper footwear.

No smoking on the property.

No dogs allowed. If you must bring your dog you must keep it in your car (Not advised in Florida)

All riders, boarders, lessees and guests must sign a “Liability Release”, a “Covenant Not To Sue”, “Medical Release”, and a “Rules: form before handling or riding any horse. No exceptions.

It is the boarder’s responsibility to ensure that all his or her authorized guests, and or lessees have completely filled out these four forms. No exceptions.

Do not use other boarder’s equipment without their express permission.

Gate to your horse’s paddock must be secured with clip. When your horse’s paddock is empty, the gate must be left in either the closed position or opened inward into the paddock.

Do not go into the tractor barn without permission.

Tie only in the crosstie areas, paddocks or stalls.

Do not mount or ride your horse on concrete and/ or asphalt surfaces. Lead your horse very slowly on these surfaces. No exceptions.

ASTM/SEI approved helmet with chin harness secured must be worn at all times while mounted.

Jumping is allowed only during instruction.

Walking your horse to dressage arena use the path behind lunging arena.

No turnouts in dressage arena.

Horse rider/ handler is responsible for making sure all arena gates are properly closed when using any arena.

If you are riding alone, trail riding or using upper arena let somebody know the approximate time you will be back.

Respect Closed And No Turnout signs that are posted on arenas.

Do not let your horse eat the landscaping!

Each person is responsible for picking up after themselves and his or her horse. Clean up manure, dirt and hair from work/ wash areas before riding and after grooming.

Each person is responsible for storing grooming and personal supplies in proper places and not leaving equipment out. Items in lost and found will be donated if unclaimed in 30 days.

It is expected that parents will drop children off for lessons. However, it is not acceptable to leave children for more than 2 hours.

All children under the age of six must be with a parent/ guardian, a trainer, or seated in the tack room.

Each person is responsible for reporting any change of address or phone number to management. Horse owners should leave emergency numbers when out of town.

I understand these rules are for my well-being and my safety and also for the well-being and safety of my horse. If I disobey them it could cause serious consequences to me and/ or others. The privilege of being at Horses in Harmony may be taken away from me. I have carefully read the barn rules and agree to obey them.

I am over 21

Name (print) ___________________________

Signature ______________________________ Date _______________

Under 21

Child’s Name ___________________________ Child’s signature __________________

Parent/ Guardian Name ______________________________

Parent/ Guardian Signature ___________________________ Date _________________

MEDICAL RELEASE

If medical care is required for me or my child, (write name in space provided) ______________________________, in connection with any ______________________ activity and if normal permission is not available in a timely manner, the undersigned authorizes appropriate medical care as deemed necessary by emergency medical personnel, a physician, or the medical facility providing treatment.

RELATED INFORMATION

Name/ Parent or Guardian: _________________________________________________

Address: ________________________________________________________________

Phone (home): __________________ Business _______________ Cell ______________

Emergency contact: _______________________________________________________

Emergency contact phone: __________________________________________________

PHYSICIAN: ____________________________________________________________

Known allergies to: _______________________________________________________

Medication(s) currently being taken: __________________________________________

For: ____________________________________________________________________

Date of Birth: ________________

Medical Insurance company: ________________________________________________

Policy Number: __________________________________________________________

SPECIAL INSTRUCTION TO BE COMPLETED BY PARENT / GUARDIAN: As Parent or Guardian of the above named child, please attempt to contact me at the time of an accident or illness without postponing medical treatment.

Other information/ instructions: ______________________________________________

I HAVE READ THE MEDICAL RELEASE AND AGREE TO ITS TERMS:

_________________________________ _______________ Name/ Parent or Guardian Date

COVENANT NOT OT SUE FOR ACCIDENTAL INJURIES AND LIABILITIES

For, and in consideration of, the use of the boarding stable property, operated by Horses in Harmony, the undersigned, on behalf of himself (herself) and his (her) heirs, legal representative, successors and assigns, hereby agrees to refrain from bringing suit or proceeding at law or in equity against Horses in Harmony, a corporation, or against any officer, director, manager, trainer, agent, employee, or shareholder of said corporation, either severally or jointly, on account of any and all injuries to person or property, death of any person or any horse, or any other claims, demands, damages, costs, loss or services, expenses or compensation, which in any way arise out of or are in any way connected with the use of the boarding stable property at 36201 County Road 439, Eustis, Florida 32736, or the boarding, riding, use or occupancy of said stable property by any horse. The undersigned acknowledges that he (she) has not been given permission to use or ride on any property adjoining the stables.

It is further understood that the “Covenant Not To Sue” is also to be constructed as a general release of Horses in Harmony, a corporation, or against any officer, director, manager, trainer, agent, employee, or shareholder of said corporation, of any and all types of liability that might be incurred as a result of personal injuries or death sustained by any persons or animal which are directly or indirectly attributable to the use of the property or horses.

I further state that I have carefully read the foregoing “Covenant Not To Sue” and agree that Horses in Harmony, a corporation, or against any officer, director, manager, trainer, agent, employee, or shareholder of said corporation, shall not in any way be held legally accountable to me or my family for personal injuries or death sustained by any persons or animals which are in any way connected with the use of this property.

NAME (print) ___________________________________

SIGNATURE ___________________________________ DATE ______________

"Riding is a complicated joy. You learn something each time. It is never quite the same, and you never know it all."