Naturally Equisavvy Solutions Clinic Registration
** EACH person that will be attending a Naturally Equisavvy Solutions Clinic is required to compete this form. (Parents/Guardians, Participants, Auditors and any support personnel) Part 1: Filling out this form will act as PART 1 of your registration request to attend a Naturally Equisavvy Clinic. Please send an email to nes.naturally@gmail.com to officially request a clinic spot. PART 2: Send deposit to hold your spot. E-transfer to nes.naturally@gmail.com PART 3: Send full payment by specified date. E-transfer to nes.naturally@gmail.com By filling out this form, it confirms that you have read and understood all the information and agree with the terms specified.
DATE FILLING OUT THIS FORM
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Month
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Day
Year
Date
DATE OF CLINIC
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Month
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Day
Year
Date
NAME OF CLINIC
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LOCATION OF CLINIC
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PARTICIPANT NAME
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First Name
Last Name
BIRTHDATE OF PARTICIPANT
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Month
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Day
Year
Date
PARTICIPANT EMAIL
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example@example.com
PARTICIPANT HOME ADDRESS
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PARTICIPANT PHONE NUMBER
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Please enter a valid phone number.
Format: (000) 000-0000.
WHY DO WE REQUEST YOUR PERSONAL MEDICAL INFORMATION
This is for Emergency use only - in case an accident happens. "Emergency Cards" are created and carried to all events. These cards will only be used to hand over to EMT's so they have all specific health information needed to provide you with the emergency care needed.
HEALTH CARD PROVINCE
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PEI
NS
NB
NFLD
Other
HEALTH CARD #
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DOCTOR'S NAME & LOCATION
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MEDICAL INFORMATION/ALLERGIES/MEDICATIONS
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EMERGENCY CONTACT NAME
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First Name
Last Name
EMERGENCY CONTACT PHONE NUMBER
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Please enter a valid phone number.
Format: (000) 000-0000.
EMERGENCY CONTACT IS MY
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Guardian
Grandparent
Friend
Other
Husband
Wife
Partner
Parent
CONCUSSION AWARENESS INFORMATION
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By placing a mark below, I ATTEST that I have read and understand the CONCUSSION AWARENESS Information
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Yes
GENERAL WAIVER INFORMATION
All attendees at a Naturally Equisavvy Solutions Clinic must read and agree to the GENERAL WAIVER Information provided.
GENERAL WAIVER FORM - By placing a mark below, I agree:
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1) I Understand there are Inherent DANGERS, HAZARDS and RISKS, (collectively called RISKS) associated with Equine Activities and injuries resulting from these “RISKS” are a common occurrence.
2) I Acknowledge that the Inherent “RISKS” of Equine Activities mean those DANGEROUS conditions which are an integral part of Equine Activities, including but not limited to:
2a) The propensity of any equine to behave in ways that might result in injury, harm or death to persons on or around them and to potentially collide with, bite or kick other animals, people, or objects.
2b) The unpredictability of an equine’s reaction to such things as sounds, sudden movement, tremors, vibrations, unfamiliar objects, persons or other animals and hazards such as subsurface objects.
2c) The potential for other participant (s) to act in a negligent manner that might contribute to injury to themselves or others, such as failing to act within their ability or to maintain control over an equine.
3) I Freely Accept and Fully Assume All Responsibility for the Inherent “RISKS” and the possibility of personal injury, death, property damage or loss resulting from my Participation in Equine Activities.
4) I Acknowledge that it remains my Sole Responsibility to act in such a manner as to be responsible for my own safety and to Participate Within My Own Limits.
5) In addition to consideration given for my Participate in Equine Activity, I and my heirs, executors, administrators and assigns (collectively called my “Legal Representatives”) agree :
6) To Waive All Claims that I might have against the “HOST”; and
6a) To Release the “HOST” from Any and All Liability for any loss, damages, injury, or expense that I or my “Legal Representatives” might suffer as a result of my Participation due to any cause whatsoever including any NEGLIGENCE ON THE PART OF THE “HOST”; and
6b) To HOLD HARMLESS AND INDEMNIFY THE “HOST” from any and all liability for property damage or personal injury to any third party which might result from my Participation in Equine Activities.
7) I acknowledge that I HAVE INFORMED MYSELF OF ALL RELEVANT RISKS.
8) I acknowledge that there may be RULES and REGULATIONS applicable to the sport or activity I wish to participate in, and that they are designed for enhancement of safety and protection of myself and other participants. I have informed myself of whether such RULES and REGULATIONS EXIST, AND IF THEY DO I undertake to abide by them.
By placing a mark below, I ATTEST that I have read and agree with the GENERAL WAIVER Information
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Yes
NATURALLY EQUISAVVY SOLUTIONS WAIVER - By placing a mark below, I agree to each of the following:
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I will be respectful to all participants, organizers and all people in attendance
I will not be a "Side Line Coach"
I will speak quietly to other attendees, so I do not cause distractions
I will think before I act so that I will not disturb the participants or their equines
I will have an open mind to new concepts, be positive and have fun!
I will follow the safety guidelines set out by Naturally Equisavvy Solutions and the host facility
I understand that I may be asked to actively participate in activities (I can say no thanks if I am uncomfortable)
By placing a mark below, I ATTEST that I have read and agree with the NATURALLY EQUISAVVY SOLUTIONS WAIVER Information:
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Yes
HOW WILL YOU BE PARTICIPATING?
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Auditor or Support Person
Adult Participant
Youth Participant (19 years and under)
How Will You Be Participating? Auditor or Support Person
How Will You Be Participating? Adult Participant
How Will You Be Participating? Youth Participant
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YOUTH SECTION
NAME OF YOUTH PARTICIPANT
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First Name
Last Name
ARE YOU THE PARENT OR GUARDIAN OF THE YOUTH PARTICIPANT?
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Parent
Guardian
PARENT or GUARDIAN NAME
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First Name
Last Name
PARENT or GUARDIAN PHONE NUMBER
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Please enter a valid phone number.
Format: (000) 000-0000.
PARENT or GUARDIAN EMAIL ADDRESS
example@example.com
UPLOAD LEGAL GUARDIANSHIP DOCUMENT - this is a required document if applicable
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By printing my name below, I hereby acknowledge and affirm that I have read and fully understand the contents of this document and agree to be bound by its terms. PRINT AUTHORIZING PARENT or GUARDIAN NAME
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AUDITOR or SUPPORT PERSON SECTION
"Auditor" (clinic spectator) will observe the clinic from the sidelines. A "Support Person" is someone who will be assisting a participant with preparations for the clinic from the sidelines.
Have you attended other Naturally Equisavvy Solutions clinics as an Auditor or Support Person?
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Yes, as an auditor
Yes, as a support person
No
I have audited other clinics from different clinicians
I am attending this clinic as
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Auditor
Support Person
If you are a Support Person, provide name of Participant
What are your expectations as an auditor or support person?
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By printing my name below, I hereby acknowledge and affirm that I have read and fully understand the contents of this document and agree to be bound by its terms. PRINT AUTHORIZING AUDITOR or SUPPORT PERSON NAME
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Signature of AUDITOR OR SUPPORT PERSON
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PARTICIPANT SECTION
Have you attended other Naturally Equisavvy Clinics as a participant?
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Yes
No
I have participated other clinics from different clinicians
I attest that I have Island Horse Council or other Province Insurance
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Yes, I have Island Horse Council Insurance
Yes, I have another province insurance policy
No, I do not have insurance but I will purchase it and provide proof of purchase before the clinic
Island Horse Council Membership # OR Other Provincial Insurance Information (enter "GET" if you currently do not have insurance but are purchasing it)
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What are your expectations as a Participant?
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EQUINE NAME
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EQUINE BREED
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EQUINE AGE
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STABLING REQUEST
I understand that my stabling request may not be available but that Naturally Equisavvy Solutions will do their best to accommodate my selection.
REQUEST STABLING
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Stall
Paddock
No request
I plan on hauling in prior to the first day of the clinic day (I understand there is an additional fee)
Yes, 1 day before
Yes, 2 days before
No, I will haul in the day of the clinic
Information the clinician or host facility should know about you or your equine partner
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By printing my name below, I hereby acknowledge and affirm that I have read and fully understand the contents of this document and agree to be bound by its terms. PRINT PARTICIPANT NAME
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Signature of Participant
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By printing my name below, I hereby acknowledge and affirm that I have read and fully understand the contents of this document and agree to be bound by its terms. PRINT AUTHORIZING PERSON of YOUTH NAME
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Signature of AUTHORIZING PERSON of YOUTH NAME
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