Summer Horsemanship Sessions 2020 Registration & Release Form
Rider Information
Name
*
First Name
Last Name
Age
*
Birth Date
-
Month
-
Day
Year
Date
Sex
*
Male
Female
Height
Weight
Please indicate your child's level of riding experience. *
*
None
Beginner - walk
Beginner - walk, trot
Beginner - walk, trot, canter
Intermediate - walk
Intermediate - walk, trot
Intermediate - walk, trot, canter
Advanced - walk
Advanced - walk, trot
Advanced - walk, trot, canter
Parent/Guardian Information
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Summer Horsemanship Sessions
Please select the session you wish to attend:
*
Session #1: 6/29-7/10 (2 weeks) - $1,100.00
Session #2: 7/13-7/24 (2 weeks) - $1,100.00
Session #3: 7/27-8/7 (2 weeks) - $1,100.00
Session #4: 8/10-8/21 (2 weeks) - $1,100.00
Session #5: 8/24-9/4 (2 weeks) - $1,100.00
If you would like to select an additional session, please do so below.
Session #1: 6/29-7/10 (2 weeks) - $1,100.00
Session #2: 7/13-7/24 (2 weeks) - $1,100.00
Session #3: 7/27-8/7 (2 weeks) - $1,100.00
Session #4: 8/10-8/21 (2 weeks) - $1,100.00
Session #5: 8/24-9/4 (2 weeks) - $1,100.00
If you would like to select an additional session, please do so below.
Session #1: 6/29-7/10 (2 weeks) - $1,100.00
Session #2: 7/13-7/24 (2 weeks) - $1,100.00
Session #3: 7/27-8/7 (2 weeks) - $1,100.00
Session #4: 8/10-8/21 (2 weeks) - $1,100.00
Session #5: 8/24-9/4 (2 weeks) - $1,100.00
If you would like to select an additional session, please do so below.
Session #1: 6/29-7/10 (2 weeks) - $1,100.00
Session #2: 7/13-7/24 (2 weeks) - $1,100.00
Session #3: 7/27-8/7 (2 weeks) - $1,100.00
Session #4: 8/10-8/21 (2 weeks) - $1,100.00
Session #5: 8/24-9/4 (2 weeks) - $1,100.00
If you would like to select an additional session, please do so below.
Session #1: 6/29-7/10 (2 weeks) - $1,100.00
Session #2: 7/13-7/24 (2 weeks) - $1,100.00
Session #3: 7/27-8/7 (2 weeks) - $1,100.00
Session #4: 8/10-8/21 (2 weeks) - $1,100.00
Session #5: 8/24-9/4 (2 weeks) - $1,100.00
Do you give permission for anyone else to pick up your child?
*
Yes
No
If yes, please provide details.
Emergency Contact
Name
*
First Name
Last Name
Relationship to Rider
*
Phone Number
*
-
Area Code
Phone Number
Child’s Health Information
Does your child have any allergies?
*
No
Yes
If yes, please provide details.
Is your child currently taking any medication?
*
No
Yes
If yes, please provide details.
General Release and Authorization
General Release and Authorizations Accuracy of Information: Health history is correct so far as I know and the person herein described has permission to engage in all horsemanship activities except as noted. Photo Release: I authorize Harlequin Stables to have my child’s photo appear in camp brochures, videos, on websites or other promotional literature. Authorization for Treatment: In case of an emergency, I authorize Harlequin Stables to administer first aide and to transport my child to the nearest hospital emergency room. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director or his/her designee to secure and administer treatment, including hospitalization, for the person named below. ***WARNING***Under Massachusetts Law, an equine professional is not liable for injury to, or the death of, a participant in equine activities resulting from the inherent risks of equine activities, pursuant to section 2D of Chapter 128 of the Massachusetts General Laws. I the rider (parent/guardian if rider is under 18) by signing below, acknowledge and recognize the inherent risks of horseback riding and assume all responsibility and risks inherent in the contact with, and riding of horses at Harlequin Stables. I further agree to hold Harlequin Stables and all agents of Harlequin Stables including, but not limited to, employees, owners, and instructors, free from responsibility or liability for damages of injury to persons or property resulting from the contact with or use of horses, equipment, or from any cause whatsoever while on Harlequin Stables’ premises. Harlequin Stables assumes no responsibility for damage to persons or property and I acknowledge that riders are at their own risk and in full understanding of the inherent risks of the sport aforementioned. The Undersigned (the rider/the guardian) acknowledge that they have read, understand, and will abide by all rules and regulations set forth by the facility and/or the management. BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE IS EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE. You may choose to sign either by typing your full name below or signing in box underneath. You may also complete both.
*
I have read and understand the terms and conditions above.
Electronic Signature - Full Name of the Undersigned:
*
Signature:
Submit
Should be Empty: