PLEASE READ CAREFULLY,SIGN, AND RETURN ALL 3 PAGES.

SUMMER WIND STABLES

                                                                                                                           11770 CHILLICOTHE RD.

                                                                                                                         CHESTERLAND, OH  44026

                                                                                                                              729-1849           729-7430

 

RIDING INSTRUCTION AGREEMENT AND LIABILITY RELEASE FORM FOR INDIVIDUAL

I, ____________________________________________________________,Parent or guardian of said child, or adult signing for self,

do hereby give my permission for   r myself, r my child(ren), _________________________________, of (include full address and phone number)_______________________ ________________________________________________________________to ride any horse of Conni Bryan-Lawrence, owner of Summer Wind Stables, or any other assigned horse they so designate

 

WHERE DID YOU HEARD ABOUT SUMMER WIND STABLES???_____________________________

EMAIL ADDRESS ______________________________________________________________________

 

REGISTRATION OF RIDERS AND AGREEMENT PURPOSE.  In consideration of the payment of a fee and the signing of this agreement, I, the following listed individual and the parent or legal guardians there of if a minor, do hereby voluntarily request and agree to participate in riding instructions as a student at Summer Wind Stables, and affirm that this student will either ride his/her own horse, a school horse provided by Summer Wind Stables for instructional purposes,or any other horse Summer Wind Stables so designates, today and on all future dates.                                                                                                                                                         

I grant permission for Conni Bryan-Lawrence, or any other instructor so designated by Conni Bryan-Lawrence to give instruction in horsemanship to myself / my child.  It is understood that I will assume all risk pertaining to said horse, and instruction, and release Conni Bryan-Lawrence, their successors and assignees from any and all claims arising by reason of any matter, cause or thing from myself / my child being near any horse owned by Summer Wind Stables or used on the property owned, leased or used by Conni Bryan-Lawrence, their successors, and assigns or any horse associated with them.  This would also include any time said student is away from the property owned by Conni Bryan-Lawrence with said horses.

 

      Rider 1 Name                                    Age                     Approx. weight           Horse Riding Experience  

      Rider 2 Name                                    Age                     Approx. weight           Horse Riding Experience

      Rider 3 Name                                    Age                     Approx. weight           Horse riding experience                                                                                                                             ____  Beginner (under 10 hours) _________    ____________     __________

      ____  Over 10 hours   _________   _________      ___________ 

List any  physical or mental health problems which may affect any of these riders ability to ride a horse: 

Describe here: __________________________________________         List any of these rider’s regular medications?________________________________________________________________

B.    Agreement scope and territory and definitions.  This agreement shall be legally binding upon me the registered student, including the parents or legal guardians thereof if a minor, my heirs, estate, assigns, including all minor children, and personal representatives, and it shall be interpreted according to the laws of  Ohio.  If any clause, phrase or word is in conflict with state law, then that single part only  is null and void.  The term “horse” herein shall refer to all equine species.  The term “horseback riding” herein shall refer to riding or otherwise handling of horses, whether from the ground or mounted.  The terms “student” and/or “rider” shall herein refer to a person who rides a horse mounted or otherwise handles or comes near a horse form the ground.  The terms “I”, “me”, “my shall herein refer to the above registered student rider and the parents or legal guardians thereof , if a minor.

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 the 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 U.S. hospitals.  Related injuries can be severe, requiring more hospital days and resulting in more lasting residual effects than injuries in other activities.

D.    Nature of Summer Wind Stables school horses.  I understand that Summer Wind Stables chooses its school horses for their calm dispositions and sound basic training as is required for use for student riders, and Summer Wind Stables 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 the ground it will generally be at a distance of from 3 1/2 to 5 1/2 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 has a limited understand of the other.  If a horse is 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 and calm aboard the moving animal.  I agree that

 the rider shall be responsible for his/her own safety. 

A.  Protective Head Gear.  Each horse handler should consider wearing properly fitted and secured protective headgear (equestrian riding helmet),  bearing the standard ASTM/SEI emblem.  Wearing of such headgear while driving, mounting, riding, dismounting and being around horses, may prevent or reduce severity of some head injuries and may even prevent death as the result of a fall and/or other occurrences.

B.    Foot Protection.  Horse handlers, riders and drivers should wear hard, smooth-soled Western or English riding boots with heels (and socks) to provide protection for the feet in event that a horse ______ steps on a foot, and also to assist in preventing the foot from slipping all the way through the stirrup and becoming caught while riding, mounting, dismounting, and/or other occurrences.  Soft socks provide additional protection against chafing and allow for easier removal of the foot from the boot.

C.    Clothing.  Horse handlers, riders and drivers should wear long pants to protect legs, and riders should also consider wearing equestrian pants, breeches or jodhpurs with leather inner knee/calf patches, or chaps, or other leggings that provide inner leg grip and added stability in the saddle.

F.     Conditions of Nature.  I understand that Summer Wind Stables is NOT responsible for total or partial acts, occurrences, or elements of nature that can scare a horse, cause it to fall, or react in some other unsafe way.  Some examples are: Thunder, lightening, rain, wind, wild and domestic animals, insects, reptiles, which may walk, run, or fly near, or bite or sting a horse or person, 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.

G.    Saddle Girth/Natural Loosening.  I understand that saddle girths (saddle fasteners around horse’s belly) may loosen during 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 have been fully warned and advised by Summer Wind Stables that I must wear ASTM/SEI approved protective headgear (equestrian riding helmet)  and do 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 even prevent death from happening as the result of a fall or other occurrence.

J.     Liability Release.  In consideration of Summer Wind Stables 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 Summer Wind Stables, its owner(s), agent’s employees, officers, members, premises owners, and affiliated organizations from legal liability due to Summer Wind Stables ordinary negligence, and I do further agree that, I shall bring  no claims, demands, actions and causes of action, and/or litigation, against Summer Wind Stables and its associates as stated above in this clause, for any economic and noneconomic 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 Summer Wind Stables, to include while riding, handling or otherwise being near horses owned by or in the care, custody and control of Summer Wind Stables except in the event of Summer Wind Stables’s gross and willful negligence.

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 APPLICANTS

PHYSICAL CONDITION, EXPERIENCE AND AGE ARE TRUE AND CORRECT.

 

 

Signature of Rider _____________________________________________ (Date)

Signature of Rider # 2 if applicable___________________________________________ (Date)                                   

Rider must be over 21 or parent or guardian must also sign

Signature of both parents , Guardian  __________________________________­­­­­­­­­­­­­­­­­­­­­________________  (Date)           

Both parents must sign

      Signature of Spouse of Adult if applicable __________________________   (Date)     Must have signature

                                                 

 

 

 

This release form can be used for a child rider, or adult rider, or Boarder.  Please interchange the  wording to relate to your child, or to yourself.

1.)  Please state here if this form is for a  r  child rider r adult rider r boarder.

2.)  Name of rider/boarder: __________________________________________________________________________________

3.)  Parent/Guardian:  In case of an EMERGENCY, my parent, spouse, friend can be reached at:  ______________________________

      ____________________________________________________________________________________________________

4.)  If they are unable to be reached, please contact one of the two following people, their name, phone number and address:      1.)____

The relationship this person is to my child:  _____________________________________________________________________

      2.)__________________________________________________________________________________________________

The relationship this person is to my child:  _____________________________________________________________________

I hereby grant my permission for the above listed person(s) to make medical decision pertaining to my child or myself:

r Yes               r  No             Signature:  ________________________________________

If no one is able to be reached, I hereby give my permission for my child to be transported to ______________________

hospital by anyone associated with Summer Wind Stables. Signature: _____________________________________

I prefer my child not be transported or moved until I arrive to see them.  Yes       No    Signature:_____________________________

I prefer my child to be transported by ambulance and not moved by anyone from Summer Wind Stables:

r Yes               r  No             Signature: ________________________________________________________________________

My doctor should be contacted:        r Yes       r  No   Doctors name and phone number:  __________________________________

My dentist should be contacted :      r Yes       r  No   Dentists name and phone number:  __________________________________

MEDICAL INSURANCE INFORMATION

Insured’s Name:  _________________________________________________________________________________________

Company Name:  _________________________________________________________________________________________

Address:  _______________________________________________________________________________________________

Phone Number:  __________________________________________________________________________________________

Certificate Number:  __________________________________Group Number:  _________________________________________

Please list any medical problems in the past, or existing now that we should be aware of:  ___________________________________

__________________________________________________Allergies:  ____________________________________________

All medications being taken now:  ____________________________________________________________________________

As the parents/guardian of _____________________________ or the adult rider, we hereby grant our permission to Conni Bryan -Lawrence, Summer Wind Stables or anyone assigned by them to obtain medical and/or surgical treatment, and/or special procedures, which may be required for our child in the event we (or our above named assignee) can not be reached.  We would like to have our doctor consulted in connection with any of these procedures or treatments.    We acknowledge that Conni Bryan-Lawrence, Summer Wind Stables,  any doctor or hospital, its officers and personnel providing medical or surgical services to any child listed above, may rely upon the consent of authorization executed by the named appointee, or Conni Bryan-Lawrence, with the same force and effect as if it was personally executed by us.    This consent will be effective while my child, or myself is in the care of Conni Bryan-Lawrence or any of their assigns._______

Signature of both Parents/Guardian/Adult rider 2nd Parent                                                                    Date

In the event that this form is executed by only one parent, please state below why the signature of the other parent cannot be obtained.  If the child is under guardianship, then the guardian should execute this authorization