Naturally Equisavvy Solutions Lesson Registration
** EACH person that will be attending a Naturally Equisavvy Solutions Lesson Program is required to compete this form. (Parents/Guardians and Participants) Part 1: Filling out this form will act as your official registration request to attend a Naturally Equisavvy Solutions Lesson Program Part 2: Contact Naturally Equisavvy Solutions to book your lesson time. By filling out this form, it confirms that you have read and understood all the information and agree with the terms specified.
DATE OF FILLING OUT THIS FORM
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Month
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Day
Year
Date
NAME
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First Name
Last Name
PHONE NUMBER
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Please enter a valid phone number.
EMAIL
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example@example.com
BIRTHDATE
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Month
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Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
WHY ARE YOU BEING ASKED FOR YOUR HEALTH CARD & PERSONAL MEDICAL INFORMATION?
In the case of an emergency, NES has created Emergency Info Cards that are carried to all lessons and events. These are only used to provide to Emergency Staff so they can provide you with the proper medical services that you require.
HEALTH CARD INFORMATION:
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PEI
NS
NB
NFLD
Other
HEALTH CARD #
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DOCTOR'S NAME & LOCATION
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MEDICAL CONDITIONS/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.
RELATIONSHIP TO EMERGENCY CONTACT
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Parent
Husband/Wife/Partner
Guardian
Grandparent
Friend
Other
HOW WILL YOU BE PARTICIPATING IN THE LESSON
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Adult
Youth
HOW WILL YOU BE PARTICIPATING IN THE LESSON - ADULT
HOW WILL YOU BE PARTICIPATING IN THE LESSON - YOUTH
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PARTICIPANT SECTION
PARENT or GUARDIAN NAME of YOUTH PARTICIPANT
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First Name
Last Name
PARENT or GUARDIAN PHONE NUMBER
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Please enter a valid phone number.
PARENT or GUARDIAN EMAIL ADDRESS
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example@example.com
Youth AUTHORIZING PERSON is:
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Parent
Guardian
Proof of Legal Guardianship Document, is required if Guardian is authorizing person for a YOUTH participant.
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I agree that Naturally Equisavvy Solutions recommends 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
I choose to not purchase insurance and accept all consequences
Proof of Insurance (Island Horse Council or other Province Insurance) Membership # (enter n/a if you currently don't have insurance)
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Please describe any previous equine experience you have.
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What are your expectations and goals as a participant?
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CONCUSSION AWARENESS INFORMATION
I will read, understand and agree with the Concussion Awareness Information. Download available.
I attest that I have read, understand and agree to the above Concussion Awareness Information:
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Yes, I agree with the Concussion Awareness Information
I request clarification on Concussion Awareness
NATURALLY EQUISAVVY SOLUTIONS WAIVER INFORMATION
Every Person must Read and Understand the following statements before Participating in Equine Activities. NATURALLY EQUISAVVY SOLUTIONS & Julia Smith, their directors, employees, officers, volunteers, business operators, and site property owners. (all of them collectively called the HOST).By placing a check mark below, I attest that I have read each statement and I understand it. I know that checking these statements, waives certain legal rights I or my “Legal Representatives” might have against the “HOST”.
I AGREE to the following Naturally Equisavvy Solutions WAIVER INFORMATION:
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I will be respectful to all participants, organizers and all people in attendance
I will speak quietly to other attendeess, 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 will push my comfort zone but I will speak out if I am too uncomfortable
I agree to pay the specified fees, on time and I understand that there are additional fees if I do not pay on time
General Waiver Information
Every Person must Read and Understand the following statements before Participating in Equine Activities. NATURALLY EQUISAVVY SOLUTIONS & Julia Smith, their directors, employees, officers, volunteers, business operators, and site property owners. (all of them collectively called the HOST).By placing a check mark below, I attest that I have read each statement and I understand it. I know that checking these statements, waives certain legal rights I or my “Legal Representatives” might have against the “HOST”.
General Waiver Information - I attest:
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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:
• 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.
• 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.
• 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 :
• To Waive All Claims that I might have against the “HOST”; and
• 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
• 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.
• I acknowledge that I HAVE INFORMED MYSELF OF ALL RELEVANT RISKS.
• 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.
As the Youth Authorizing Person, I have read, understand and agree with this Naturally Equisavvy Solutions Lesson Registration form. I grant my permission for the aforenamed Youth to participate in Naturally Equisavvy Solutions lesson program.
I attest my approval for the aforenamed Youth to be a Participant
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Yes
I request more information
SIGNATURE - print Authorizing Signature or Adult Participant Signature
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Signature of Authorizing Person or Adult Participant
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