Riding Application form

Confidential Riding Application and Medical History Form
Riders name*
Contact Number*
Email*
example@example.com
Age if under 18yo
Approximate weight of rider*
Used only to ensure the correct horse is available. We currently have horses suitable to carry riders up to 100kg only.
How many times has the rider ridden in total?*

0 - 1010 - 2020 - 5050 - 100100
The number of times the rider has ridden in the last 12 months*
In the case of any emergency the following information is intended to assist:

Name and telephone numbers of contact people.** Legal gardian details must be provided if rider is under 18 years of age
Emergency contact name*
Relationship with rider*
Mobile*
Home
Emergency contact name
Relationship with rider
Mobile
Home
Are there any learning difficulties that need to be discussed, so the Instructors/Guides are able to accommodate accordingly?
Please describe
Do you (or your child) suffer from any of the following?

NO (Please tick if applicable)
Please tick: Any pre-existing medical or other condition that may affect or risk other persons or myself.

AsthmaDiabetesEpilepsy / FitsFaintingBlackoutsDisabilityBack injuryHeart ConditionBlood ConditionPregnancyDizzinessMigrainesUneven PupilsMedicationsAllergic ReactionsRecent injury
Recent injury
Allergies
Please describe allergy
Tetanus Immunisation
It is particularly important that people dealing with horses are immunised against tetanus. Tetanus is normally given at five years of age as Triple antigen or CDT and at fifteen years of age as ADT.
Year of last tetanus immunisation
Medication
Is it necessary for you or your child to carry their own medication at all times?
Name of drug
Frequency
Dosage
Consent To Medical Attention
I authorise the instructor in charge to administer first aid and call an ambulance. I agree to bear any cost thereby incurred. Horse riding is a dangerous sport and Ambulance cover is recommended for any participant.

If under 18 this form must be signed by a parent or legal gaurdian
Signature

Clear
Date

MonthDayYear
Date
Payments and Cancellations Policy
Lesson places are booked for a full term. Payment can be made in full at the beginning of the term or weekly/fortnightly via automatic direct deposit which will be taken out on the Saturday prior to your lesson. Payments on the day via cash or card are also accepted, however, card details must be kept on file for charge of any cancellation fees owing.

We understand that life happens and sometimes you cannot make your lesson. For any cancellations made with more than 24 hours notice you will be offered a make up lesson or if paying on the day you will not be charged a fee. The make up lesson needs to be made up in the same term and cannot be transferred to another term or any other rider. You will be given 3 lesson times which we can offer a make up lesson. If you cannot make any of these sessions then make up lesson will be forfeited.

Cancellations within 2 hours will not be offered a make up lesson or refund without a medical certificate.

One trial lessons will be available for those who wish to trial lessons prior to booking in for the term.

*A term will run the same as a school term. Signing up to lessons part way through the term is welcome and you will only be charged for the remainder of the term.

By signing below I agree to all of the above terms and conditions and conditions as well as the payment and cancellation policy.

Pants and enclosed toe boots with a smooth sole and small heel must be worn while riding and handling the horse, If you wear incorrect clothing and we do not have the correct size boots for you to borrow, you will forfeit you lesson. Helmets can be borrowed for your first 3 lessons, after that we ask that you purchase your own helmet.
I agree to the following: (all must be ticked to be accepted)*

I give Ajay Equestrian permission to direct debit my account or credit card for fees associated with horse riding lessons including cancellation fees.I give my permission for my card or bank account details to be kept on file for as long as I am a client of Ajay EquestrianI will let Ajay Equestrian know in writing that I would like to cancel my lessons prior to the beginning of the following term to avoid paying fees for the next termI will take full responsibility for any injury, death or damage to self or property that may occur while riding or being present at Ajay EquestrianI understand that I am responsible for purchasing my own insurance for personal injury and acknowledge that Ajay Equestrian, its staff, volunteers and owners are not responsible to cover any bills or loss of income associated with any injuryI will read and follow all signs on the property and follow all instructionsI will wear an Australian Standard Approved helmet and the correct footwear at all timesI will only ride the horse in a safe and controlled mannerI have read and understood the cancellation policy and payment termsThe Instructor/Guide may cancel my ride without refunding any fee if I do not comply with any of these terms and conditions
Privacy Statement – Privacy Act 1998
By completing this form you are supplying Ajay Equestrian with personal information about yourself. This information is needed to ensure your safety during your time with us. Ajay Equestrian is required to collect this information by our insurance company and by the department of Workplace Health and Safety. This information you provide will not be supplied to any other organisation or used for any other purpose than that which is stated above
Name*

First NameLast Name
Please sign below to give Ajay Equestrian permission to charge your credit card for any outstanding lesson fees. We will contact you via phone for card details*

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Confidential Riding Application and Medical History Form

Allergies

Tetanus Immunisation

Medication

Consent To Medical Attention

Payments and Cancellations Policy

Privacy Statement – Privacy Act 1998