New Customer Registration Form

Riders Name *

First Name Last Name

Date of Birth *

Height *

Weight *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number *

Area Code Phone Number

E-mail *

Occupation *

Contact Name/Number in case of Emergency *

Please details any disability or Medical condition which may affect your ability to ride or which your instructor should be made aware of in the case of an emergency (e.g Back Problems, asthma, diabetes etc *

Riding Abilities - I would consider myself/my child to be a: *

Lead Rein - unable to ride independently / Never Ridden Beginner - able to walk/trot independently Novice Intermediate

How many lessons have you/your child had in the last 12 months? *

None Less than 5 5-10 10+

What do you believe your capabilities on an average horse to be? *

Never Ridden Before Riding at Walk (Off Lead Rein) Trotting Cantering Galloping Riding over 0.5m Jumps Riding over 0.75m Jumps

How did you hear about us? *

Riders under the age of 16

I accept full responsibility for my child and confirm that the pre-assessed abilities are correct.

I ACCEPT MY CHILD RIDES AT HIS/HER OWN RISK

Riders 16 years and over

I acknowledge that riding is a risk sport and participation may hold potential danger, and that all horses may react unpredictably on occasions. I agree that I RIDE ENTIRELY AT MY OWN RISK. I understand that I must obey the instructions of the Instructor and comply with the health and safety requirements of this establishment.

I confirm to the best of my knowledge that all the above details are correct, and I have read Parbold Equestrian Centre's Terms and Conditions (including the cancellation polocy) and the Riders code of conduct and agree to abide by this. This form must be signed by a parent or guardian of riders under the age of 16.

Signature *

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Date

Customer Details: