Week Applying For:___________________

 

351 W. Samaria Rd.  Temperance, MI  48182

 

 RIDING DAY CAMP & LESSON SERIES

APPLICATION

PERSONAL INFORMATION REGARDING APPLICANT AND FAMILY

Due to the smaller stature of our school horses,

we have a rider weight limit of 195 pounds.

APPLICANT NAME: 

AGE:                     HEIGHT:    

ADDRESS: 

PHONE:  

CITY/STATE/ZIP:

MOTHER'S NAME:

WORK PHONE:

FATHER'S NAME:

WORK PHONE:
EMAIL ADDRESS:

CLOSEST RELATIVE OTHER THAN PARENTS:

PHONE:

APPLICANT'S RIDING EXPERIENCE:       _____ NONE   _____1-5 TIMES   _____10-20 TIMES  _____ JUMPING

 

LIST OTHER INTERESTS OR HOBBIES OF APPLICANT:

 

 

MEDICAL HISTORY AND INFORMATION

 

MEDICAL INSURANCE CARRIER: 

POLICY #:    

 

iF MINOR, IN CASE OF MEDICAL EMERGENCY I  GIVE PERMISSION TO SECURE TREATMENT FOR MY CHILD.

 

PARENT SIGNATURE                                             SOCIAL SECURITY #

APPLICANT PHYSICAL DISABILITIES:

APPLICANT ALLERGY OR OTHER CONDITIONS:

LAST TETANUS ADMINISTERED:

 

I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION, AND THE INFORMATION I HAVE SUBMITTED IS COMPLETE AND CORRECT.

 

PARENT SIGNATURE

 

STONEHAVEN FARMS

CONTRACT TO ASSUME RISK & WAIVE LIABILITY

DAY CAMP AND LESSON PROGRAM

 

I represent that I am an adult signing on my own behalf of my minor child named

_______________________________________________ and that I wish to take riding and horsemanship instruction at Stonehaven Farms, 351 W. Samaria Rd., Temperance, MI  48182.

 

I understand that riding horses and working in the stable area have inherent dangers, and that serious injuries, and even death may be caused in a horse-related accident.  By way or illustration, a horse related accident includes, but is not limited to, being stepped on, kicked, or otherwise struck by a hoof, bitten, pushed, knocked over, or fallen from a horse.

 

Stonehaven Farms and it's agents, employees, and volunteers have represented to me that it will use all reasonable care in their selection of horses it allows me or my child to ride, and safety in supervising my riding lessons. I understand that by nature, horses are skittish and unpredictable animals and that even the quietest of horses can occasionally act in an unanticipated manner.  I understand that the agents of Stonehaven Farms, it's employees, and volunteers cannot prevent accidents, and I do not expect them to do so.  I have been specifically advised that I can expect to fall from a horse in the natural course of learning to ride.  If at any time during a lesson I become fearful to the point I wish to dismount, I will so advise my Stonehaven Instructors.

 

Stonehaven has notified me that I must either purchase a properly fitted riding helmet whose design meets the ASTM standard #F163-8, or use one provided by this farm.  I am fully aware that this helmet must be worn whenever mounted or working around horses in order to help insure my safety.  I have been advised that any other helmet is not appropriate protective headgear for equine activities.

 

I have read this contract, understand it completely, and execute it voluntarily with full knowledge of its consequences.

 

 

Participant's Signatures

Date
Parent or Guardian's Signature Date
Stonehaven's Signature Date

WARNING:

UNDER THE MICHIGAN EQUINE ACTIVITY LIABILITY ACT, AN EQUINE PROFESSIONAL IS NOT LIABLE FOR AN INJURY TO OR THE DEATH OF A PARTICIPANT IN AN EQUINE ACTIVITY RESULTING FROM AN INHERENT RISK OF THE EQUINE ACTIVITY.

 

This form will be used to prove that you understand fully the risks of horseback riding, and that you have made a free choice to ride at Stonehaven Farms.

 

This form also restricts or eliminates your liability to file a lawsuit against Stonehaven Farms and it's agents for injuries you may have sustained while on the premises.