CJ Legacy General Contact - Waiver Release

Are you a student taking lessons or a guest on the property? (Select one)*

StudentGuest
Parent Information
Parent / Guardian 1*

First NameLast Name
Phone Number
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Mobile Number*
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Work Number*
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Phone Number
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Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Information

Provide at least 3 if possible
Emergency Contact 1*

First NameLast Name
Emergency Contact 1 Phone Number*
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Relationship 1*
Emergency Contact 2

First NameLast Name
Emergency Contact 2 Phone Number
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Relationship 2
Emergency Contact 3

First NameLast Name
Emergency Contact 3 Phone Number
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Relationship 3
Medical Information
Medical History (please mark all the following that apply to camper)*

Contacts / GlassesAsthmaDiabetesSeizure DisorderActivity RestrictionsEmotional, Social, LearningNoneOther
If "Yes" to any of the above, please explain:*

Allergy HistoryAllergies (non life-threatening environmental, medication, food)Severe or life-threatening FOOD allergiesOther Severe or life-threatening allergiesPlease list the allergen and describe the allergic reaction
Physician & Insurance Information
Doctor's Name*

First NameLast Name
Hospital Name *
Physician Phone Number*
Please enter a valid phone number.
Physician Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I / We agree that: Should medical treatment be required, I and/or my medical insurance shall pay for ALL such incurred expenses.*

Yes, I agree
Do you have Medical Insurance currently?*

YesNo
Hold Harmless Authorization for Pediatric Emergency Medical and/or Surgical Treatment

For the safety of Children, sound medical practice calls for this authorization. In emergencies, where the Parent/Legal Guardian or Emergency Contact of the Child cannot be reached - this form will be extremely important. The authorization granted by this form will be used only when absolutely necessary and only after every attempt has been made first to contact the Parent/Legal Guardian or Emergency Contact.

I hereby give my permission for my Child to attend CJ’S Legacy “Camp”. The Child herein described has permission to engage in all prescribed camp activities except as noted.

I hold harmless CJ’S Legacy, and/or Education Leads To Success Foundation, and their employees, agents, servants and volunteers from all risk, liability, injury, damage and loss to all persons and property which may occur to my child during or resulting from participation in the program.

I hereby authorize CJ’S Legacy, and/or Education Leads To Success Foundation to take measures in the event of a medical emergency. I hereby give permission to the medical personnel selected by CJ’S Legacy, and/or Education Leads To Success Foundation to order X-rays, routine tests, treatment, and necessary related transportation for my child.

In the event I cannot be reached in an emergency, I hereby give permission to the Physician of the hospital selected by CJ’S Legacy, and/or Education Leads To Success Foundation to secure treatment, including hospitalization, for my Child as named above.
Signature*

Clear
Date*

MonthDayYear
Date
Waiver & Release
Registration of Participant and Agreement: I above listed individual, and the parents or legal guardians thereof if a minor, do hereby voluntarily agree to participate in the equestrian services provided by this CJ’S Legacy, and/or Education Leads to Success Foundation.*

Yes, I agree
Friendly Reminders - Rules & Regulations: I / We agree to abide by all rules and regulations established by CJ’S Legacy, and/or Education Leads To Success Foundation and acknowledge that she has provided me with a copy of/or posted such rules and regulations in a clearly visible and prominent location and that I have reviewed them.*

Yes, I agree
Protective Headgear: I / We agree that: I for myself and on behalf of my child and/or legal ward have been fully warned and advised by this stable that protective headgear/helmet should be worn while riding, handling, and/or being near horses. I acknowledge that I/We will be responsible for properly securing the headgear/helmet on the participants head.*

Yes, I agree
Release of Liability: I the undersigned do not hold CJ’S Legacy, and/or Education Leads To Success Foundation, and their employees liable for any accident or injuries, including death that occurs while the above named rider, myself, or any family member is on the premises of CJ’S Legacy I understand the inherent danger of horses and horseback riding and accept the responsibility of our involvement in this sport.*

Yes, I agree
WARNING: Under Texas Law (Chapter 87, Civil Practice and Remedies code) an Equine Professional is not liable for any injury to or the death of a participant in equine activities resulting from the inherent risk of equine activities.

I HEREBY CERTIFY THAT I HAVE READ & UNDERSTAND ALL OF THE FOREGOING TERMS OF THIS AGREEMENT & EXPRESSLY ASSENT THERETO.
Signature of Parent / Guardian*

Clear
Date*

MonthDayYear
Date
Email*
example@example.com
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Parent Information

Emergency Information

Medical Information

Physician & Insurance Information

Waiver & Release