Please Print Clearly
Infant Participant's Name: ____________________________________ Date of Birth: __________________
Infants Address: ____________________________ City: __________ Prov: _______ Postal: ____________
Guardian's Name: ____________________________________________ Date of Birth: ___________________
Guardian's Address: _________________________ City: __________ Prov: _______ Postal: ____________
The Guardian must Read and Understand prior to the Infant Participating in Equine Activities
TO: ________________________________________________________,
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 the infant Participant for all legal purposes. |
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| _____ | (2) |
I 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. |
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| _____ | (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: |
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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; |
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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 |
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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. |
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| _____ | (4) |
I Freely Accept and Fully Assume All Responsibility for inherent "RISKS" and possibilities of personal injury, death, property damage or loss which might result from the infant being a Participant. |
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| _____ | (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. |
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| _____ | (6) |
In addition to consideration given for the infant to Participate in Equine Activities. I and my heirs, executors, administrators and assigns, (collectively called my "Legal Representatives";) agree: |
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To Waive All Claims that I or the infant Participant might have against the "HOSTS"; and |
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To Release the "HOSTS" from Any and All Liability for any loss, damages, injury, or expenses that I, the infant 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 |
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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. |
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Before signing this form I read it (as indicated by my initials) and I state I understand it. I further state that 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" |
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SIGNED This __________________________ day of ___________________ 20 _____ |
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_______________________________ |
____________________________________________ |
(Print Name of Host Witness to Signing & Initialing) |
(Signature of Parant/Guardian) |
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DO NOT SIGN UNTIL YOU UNDERSTAND ALL ITEMS ABOVE |
____________________________________ |
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(Signature of Host Witness) |