Butte Special Riders - Rider Registration and Release Forms
AS OF MAY 21, 2026 BUTTE SPECIAL RIDERS ONLY HAS TWO SPOTS LEFT! Please fill out the registration form by June 5, 2026. This will ensure enrollment of your child. Barb Gray (Program Coordinator) will contact you with the time your child will ride. Medical forms must be completed by your child’s healthcare provider. These can be downloaded from our website (https://www.buttespecialriders.org/students) and returned to us in person on your first day, on line or via mail by you or your healthcare provider. Students will not be able to ride without these forms completed. You can mail completed medical forms to Barb Gray at: 1302 Evans Ave, Butte, Montana 59701 or call/text her with any questions (406) 490-1715. You can also email us at buttespecialriders@gmail.com. There is a one-time $5.00 fee for insurance. Mail this in or pay when you arrive. Scholarships available, please ask about them! All our special horses cannot wait to see their friends this summer (and neither can we!).
Student Name
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First Name
Last Name
Student Age
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Student Date of Birth
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Month
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Day
Year
Date
Student Gender
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Please Select
Male
Female
Non-Binary
Prefer Not to Share
Student Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student's School / Educational Institution
Which sessions is the student interested in participating in this summer?
Session 1 (2026): June 8th, 15th, 22nd, and 29th
Session 2 (2026): July 13th, 20th, 27th, and August 3rd
Parent or Guardian Name
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First Name
Last Name
Parent or Guardian Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent or Guardian Contact Number
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Format: (000) 000-0000.
Parent or Guardian Email Address
*
example@example.com
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 Relationship to Student
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LIABILITY RELEASE: The student listed in this application would like to participate in the Butte Special Riders program. I acknowledge the risks and potential for risks of horseback riding. However, I feel that the possible benefits to me/my son/my daughter/my ward are greater than the risk assumed. I hereby, intending to be legally bound, for myself, my heirs and assigns, executors or administrators, waive and release forever all claims for damages against Butte Special Riders, it's Board of Directors, Instructors, Therapists, Aides, Volunteers and/or Employees for any and all injuries and/ or losses I/my son/my daughter/my ward may sustain while participating in the program.
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Date of Signature
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Month
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Day
Year
Date
PHOTO RELEASE CONSENT:
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I hereby consent to and authorize the use and reproduction by Butte Special Riders of any and all photographs and any other audiovisual materials taken of me/my son/my daughter/my ward for promotional printed material, educational activities or for any other use for the benefit of the program.
I DO NOT consent to or authorize the use and reproduction of any photographs or audiovisual materials taken by Butte Special Riders.
PHOTO RELEASE CONSENT:
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PHOTO RELEASE NON-CONSENT:
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Date
*
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Month
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Day
Year
Date
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Rider Authorization for Emergency Medical Treatment Form
In the event emergency, medical aid/treatment is required due to illness or injury during the process of receiving services or while being on the property of the agency, I authorize Butte Special Riders to: 1.) Secure and retain medical treatment and transportation, if needed; and 2.) Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.
Student Name
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First Name
Last Name
Student Date of Birth
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Month
-
Day
Year
Date
Student Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Home Phone Number (Parent or Guardian)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please provide a second emergency contact (in the event that the emergency contact listed above cannot be reached):
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First Name
Last Name
Emergency Contact #2 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please provide an additional emergency contact (in the event that the emergency contacts listed above cannot be reached):
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First Name
Last Name
Emergency Contact #3 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Physician Name
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First Name
Last Name
Primary Physician Practice Facility (Name of Clinic or Hospital)
*
Primary Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Physician Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Physician Email (or Primary Physician Practice Email)
*
example@example.com
Preferred Medical Facility
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Preferred Medical Facility Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health Insurance
*
Health Insurance Policy Number
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CONSENT PLAN:
This authorization includes x-ray, surgery, hospitalization, medication and any treatment deemed "life-saving" by the physician. This provision will only be invoked if the emergency contact, parent, or guardian are unable to be reached.
Signature
Date
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Month
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Day
Year
Date
NON-CONSENT PLAN:
I DO NOT give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency. In the event emergency treatment/aid is required, I wish the following procedures to take place:
Please prescribe the following procedures requested to take place below:
Signature
Date
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Month
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Day
Year
Date
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Butte Special Riders Release of All Claims:
The undersigned rider/volunteer (and rider/volunteer's parents) hereby agrees to the following terms and conditions of leading or walking, mount/dismount with horses of Kissock Horse Center or through the Butte Special Riders: 1. Rider/volunteer will use the horse only as instructed by the riding instructor. 2. Rider/volunteer will take all steps possible to ensure the horse's safety as well as rider/volunteer's own safety. 3. Rider/volunteer assumes all risks associated with horses and agrees not to hold Kissock Horse Center or Butte Special Riders, their proprietors, staff, employees, or any other agents of Kissock Horse Center or ·Butte Special Riders whomsoever liable for any injuries sustained by rider/volunteer while engaged in horseback riding or other associated activities in, at, or near Kissock Horse Center or the Butte Special Riders. 4. Rider/volunteer hereby releases Kissock Horse Center and the Butte Special Riders, their proprietors, staff, employees, or any other agents of Kissock Horse Center or Butte Special Riders whomsoever of and from any and all liability resulting from horsebackriding and horse-related activities.Rider/volunteer warrants that rider/volunteer has read the above and understands its terms.
Signature
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Printed Name
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First Name
Last Name
Date
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Month
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Day
Year
Date
PARENT OR GUARDIAN MUST SIGN THE RELEASE BELOW IF RIDER/VOLUNTEER IS UNDER 18 YEARS OF AGE.
I, the undersigned parent of rider/volunteer, hereby release Kissock Horse Center and theButte Special Riders whomsoever, of and from any and all liability for injuries or damages to the rider/volunteer, rider/volunteer's parents or his heirs at law resulting from horseback riding and associated activities and further agree to indemnify and hold harmless Kissock Horse Center and Butte Special Riders whomsoever from any loss suffered by Kissock Horse Center and theButte Special Riders, their proprietors, staff, employees or any other agents of Kissock HorseCenter and the Butte Special Riders whomsoever, caused by my child while horseback riding or engaging in horse-related activities.
Signature
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Printed Name
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First Name
Last Name
Date
*
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Month
-
Day
Year
Date
Please email us at buttespecialriders@gmail.com or call Barb Gray if you have any questions at (406) 490-1715.
Submit
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