Kandanga Stables - Confidential Riding Application and Medical History Form

Confidential Riding Application and Medical History Form
Riders name: (first and last name)*
Contact Number/s:*
Over 18 (check box)
Age (if under 18)
I agree to the following:*

I will only ride the horse in a safe and controlled mannerI will wear an Australian Standard Approved helmet and the correct footwear at all timesI will read and follow all signs on the property and follow all instructionsThe Instructor/Guide may cancel my ride without refunding any fee if I do not comply with any of these terms and conditions
Riding Experience - The number of times the rider has ridden in the last 12 months*
Riding experience - indicate below the number of times the rider has ridden in total*

0 - 10 Little Experience10 - 20 Some Experience20 - 50 Average Experience50 - 100 Experienced100+ Very Experienced
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 1*
Relationship with rider*
Mobile*
Home
Work
Emergency contact name 2
Relationship with rider
Mobile
Home
Work
Emergency contact name 3
Relationship with rider
Mobile
Home
Work
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 pre-existing medical or other conditions below?*

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

AsthmaDiabetesEpilepsy / FitsFaintingBlackoutsDisabilityBack injuryHeart ConditionBlood ConditionPregnancyDizzinessMigrainesUneven PupilsMedicationsAllergic ReactionsRecent injuryOther
Recent injury*
Allergies
Do you (or your child) suffer have any allergies?*

YES (Please describe below if applicable)NO
Please describe allergy and reaction
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.
Signature*

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Date*

DayMonthYear
Date
Signature of Legal Guardian (if participant is U/18)
Signature

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Privacy Statement – Privacy Act 1998
By completing this form you are supplying the Provider with personal information about yourself. This information is needed to ensure your safety during your time with us. The Provider 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
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Confidential Riding Application and Medical History Form

Allergies

Tetanus Immunisation

Medication

Consent To Medical Attention

Privacy Statement – Privacy Act 1998