Shady Hollow Assisted Riding

Registration Form

Program Applying to:

Bridle Club	Summer Camp
Assisted Riding Lessons	Able Riding Lessons
Programs Volunteering	Non-Programs Volunteer

First Name: Last Name: Phone: ( ) -
Address Info.: City: State: Zip Code:
E-mail Address: Cell Phone: ( ) -
Age: D.O.B Year: School:
If under 18, Parents Names:

Photo Release:
I consent to and authorize the use and reproduction by Shady Hollow Assisted Riding of any photographs and any other audio-visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.

Date: ____________ Parents/Volunteer Signature: ______________________________

Liability Release:
To participate in any program at Shady Hollow Riding, I acknowledge the risks and potential for risks of horseback riding and associated activities. However, I feel that the possible benefits are greater than the risk assumed. I hereby, intending to be legally bound, for myself, my heirs, and assigns, executers, and administrators, waive and release forever all claims for damages against Shady Hollow Assisted Riding & Shady Hollow Farms, it's owners, board of directors, instructors, therapists, volunteers, and/or losses that may be sustained while participating in Shady Hollow Assisted Riding's programs.

For this privilege I have read and agree to comply with all rules posted on the property and agree to wear an ASTM/SEI approved helmet.

Date: ____________ Parents/Volunteer Signature: ______________________________

Volunteer Programs Only: Mark Lesson Times You Will Be Attending

Tuesday	Wednesday	Thurdsay	Saturday
5:30 to 6:30	5:30 to 6:30	5:30 to 6:30	8:30 to 9:30
6:45 to 7:15		6:45 to 7:15	9:45 to 10:15
7:30 to 8:00		7:30 to 8:00	10:30 to 11:00
			11:15 to 11:45
			12:00 to 12:30

I would like to volunteer for the following programs: Bridle Club Summer Camp

Medical History:
Do you have any medical conditions that would limit your activities? Yes No
Do you have any health problems or allergies that we should know about in case of an emergency?
Please list

Authorization For Emergency Medical Treatment

In the event emergency medical aid/treatment is required due to illness or injury during the process of volunteering, or while being on the property, I authorize SHADY HOLLOW ASSISTED RIDING to:

Secure and retain medical treatment and transportation if needed.
Release volunteer records upon request to the authorized individual or agency involved in the medical emergency treatment.

Date: ____________ Signature: ______________________________

Emergency Contact Information:
Name:
Phone: ( ) -
Relationship:

Physician Contact Information:
Name: Phone: ( ) -
Prefered Medical Facility:
Health Insurance Co.: Policy#:

Consent Plan
This authorization includes x-ray, surgery, hospitalization, medications, and any treatment procedure deemed "life saving" by the physician. This provision will only be invoked if the person listed below is unable to be reached.

Date: ____________ Signature: ______________________________

Print Name: Phone: ( ) -
Address:

Non-Consent Plan
I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of volunteering or while being on the property. In the event treatment/aid is required, I wish the following procedures to take place:

Date: ____________ Signature: ______________________________

Print Name: Phone: ( ) -
Address:

Rider-$25 Yearly membership paid
Volunteer $25 Membership fee waived

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