Family Weekend Individual Forms

Emergency Information and Liability Release - Step 1
FAMILY WEEKEND EMERGENCY INFORMATION AND LIABILITY RELEASE

LITTLE SISTERS INCORPORATED DBA

WHITE PINES RANCH, 3581 PINES RD., OREGON IL 61061

PHONE: 815-732-7923 FAX: 815-732-7924 WWW.WHITEPINESRANCH.COM
Full Name *

First Name Last Name
Age *
Camper's Birthday *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail *
*

Boy Girl
This will be my camper's __ year at White Pines Ranch
Parent(s) Home Phone# *

- Area Code Phone Number
Parent(s) Cell Phone# *

- Area Code Phone Number
Parent(s) Work Phone# *

- Area Code Phone Number
In case of an emergency please contact:
Emergency Contact *

First Name Last Name
Relationship *
Phone Number *

- Area Code Phone Number
Emergency Contact *

First Name Last Name
Relationship *
Phone Number *

- Area Code Phone Number
Family Doctor's Name *

First Name Last Name
Phone Number *

- Area Code Phone Number
Medication Participant is Taking *
Any known allergies or disabilities? *
Are the participant's immunization current?
Are the participant's immunizations current?

YES NO
Date of last Tetanus shot *

- Month - Day Year
Accident/Medical Insurance Company Name *
Group Number and/or Identification Number *
(We recommend that you obtain a personal accident insurance policy if you do not already have one)
Activities that you would rather your child not participate in:
ASSUMPTION OF RISK, FULL RELEASE AND INDEMNITY
We are cognizant of the inherent dangers of participating in this program. In consideration for allowing the rancher to participate in activities and use ranch facilities, we assume all risk, agree that no claim will be made against and do fully release Little Sisters, Incorporated, it's officers, owners, employees and agents (the Program) for injury, death, damages or any loss whatsoever incurred.

We hold harmless all Program providers from all claims by family, our legal representatives and us. We assure you the rancher is in good condition and has no impairment preventing safe participation in the Program. We indemnify the Program from any loss it may incur because of our participation. We know this is a legal agreement and will be broadly interpreted releasing all joint tortfeasors.

I hereby give permission for X-rays, suturing of lacerations and other treatment deemed necessary by the attending physician in the Emergency Room.

We give permission to allow photographs or video footage of our child taken at camp to be used in White Pines Ranch’s promotional materials. We also give permission to use email information to advertise future ranch activities.
I HAVE THE LEGAL AUTHORITY TO SIGN ON BEHALF OF THE RANCHER AND FAMILY. I HAVE READ THIS
CAREFULLY AND UNDERSTAND IT. I KNOW THIS IS AS FULL AND COMPLETE A RELEASE AS IS POSSIBLE AND I HAVE SIGNED IT VOLUNTARILY.
Participant's Full Name *

First Name Last Name
Signature *

Horse Rental Agreement - Step 2
HORSE RENTAL AGREEMENT AND LIABILITY RELEASE FORM FOR INDIVIDUALS

This form must be completed by and for each participant

Little Sisters, Incorporated DBA White Pines Ranch (STABLE NAME, hereinafter known as "THIS STABLE")

3581 W. Pines Road, Oregon, Illinois 61061, Phone: 815-732-7923 Fax: 815-732-7924

PLEASE READ CAREFULLY BEFORE SIGNING

SERIOUS INJURY MAY RESULT FROM YOUR PARTICIPATION IN THIS ACTIVITY.

THIS STABLE DOES NOT GUARANTEE YOUR SAFETY.

A. REGISTRATION OF RIDERS AND AGREEMENT PURPOSE - In consideration of the payment of a fee and the signing of this agreement, I, the following listed individual, and the parent or legal guardians thereof if a minor, do horseback riding today and on all future dates:
WEIGHT OVER 240#? *

YES NO
HORSE RIDING EXPERIENCE *

UNDER 10 HOURS OVER 10 HOURS
DOES THIS RIDER HAVE PHYSICAL AND/OR MENTAL HEALTH CONDITIONS, AND/OR DISABILITIES WHICH MAY AFFECT HIS/HER SAFETY AND ABILITY TO RIDE A HORSE? *

YES NO
IF YES, PLEASE EXPLAIN:
BOTH PARENT AND CHILD MUST INITIAL EACH PARAGRAPH
B. AGREEMENT SCOPE AND TERRITORY AND DEFINITIONS - This agreement shall be legally binding upon me the registered rider, and the parents or legal guardians thereof if a minor, my heirs, estates, assigns, including all minor children, and personal representatives; and it shall be interpreted according to the laws of the state and county of THIS STABLE'S physical location. Any dispute by the rider shall be litigated in and venue shall be the county in which THIS STABLE is physically located. If any clause, phrase or word is in conflict with state law, then that single part is null and void. The term "HORSE" herein shall refer to all equine species. The term "HORSEBACK RIDING" herein shall refer to a person who rides a horse mounted or otherwise handles or comes near a horse from the ground or mounted. The term "RIDER" shall herein refer to a person who rides a horse mounted or otherwise ponies, mules, or donkeys, whether from the ground or mounted. The term "RIDER" shall herein refer to a person who rides a horse mounted or otherwise handles or comes near a horse from the ground. The terms "I", "ME", "MY" shall herein refer to the above registered rider and the parents or legal guardians thereof if a minor.
Parent initials
Rider initials
C. ACTIVITY RISK CLASSIFICATION - I UNDERSTAND THAT: Horseback riding is classified as RUGGED ADVENTURE RECREATIONAL SPORT ACTIVITY, and that there are numerous obvious and non-obvious inherent risks always present in such activity despite all safety precautions. According to NEISS (National Electronic Injury Surveillance Systems of United States Consumer Products) horse activities rank 64th among the activities of people relative to injuries that result in a stay at U.S. hospitals. Related injuries can be severe requiring more hospital days and resulting in more lasting residual effects than injuries in other activities. I/WE further understand that applicant may be participating in a “WILDERNESS EXPERIENCE” and that the meaning of this term is defined as follows: THE PURSUIT OF ADVENTURE TYPE ACTIVITY IN A WILD, RUGGED, AND UNCULTIVATED AREA OR REGION, AS OF FOREST and/or HILLS and/or MOUNTAINS and/or PLAINS and/or WETLANDS, WHICH WOULD LIKELY BE UNINHABITED BY PEOPLE AND INHABITED BY WILD ANIMALS OF MANY TYPES AND SPECIES TO INCLUDE, BUT NOT LIMITED TO, MAMMELS, REPTILES, AND INSECTS, WHICH ARE NOT TAME, MAY BE SAVAGE AND UNPREDICTABLE IN NATURE AND ALSO WANDERING AT THEIR WILL.
Parent initials
Rider initials
D. NATURE OF STABLE HORSES – I UNDERSTAND THAT: THIS STABLE chooses its rental horses for calm dispositions and sound basic training as is required for use as riding horses for novice and beginning riders, and THIS STABLE follows a rigid risk reduction program. Yet, no horse is a completely safe horse. Horses are 5 to 15 times larger, 20 – 40 times more powerful, and 3 to 4 times faster than a human. If a rider falls from horse to ground it will generally be at a distance of from 3.5 to 5.5 feet, and the impact may result in injury to the rider. Horseback riding is the only sport where one much smaller, weaker predator animal (human) tries to impose its will on another much larger, stronger prey animal with a mind of it’s own (horse) and each has a limited understanding of the other. If a horse is frightened or provoked it may divert from its training and act according to its natural survival instincts which may include, but are not limited to: Stopping short; Changing directions or speed at will; Shifting its weight; Bucking, Rearing, Kicking, Biting, or Running from danger
Parent initials
Rider initials
E. RIDERS RESPONSIBILITY – I UNDERSTAND THAT: Upon mounting a horse and taking up the reins the rider is in primary control of the horse. The rider’s safety largely depends upon his/her ability to carry out simple instructions, and his/her ability to remain balanced aboard the moving animal. I agree that the rider shall be responsible for his/her own safety, and that of an unborn child if the rider is pregnant. THIS STABLE advises pregnant women not to ride horses, unless permission is given under advice of her physician.
Parent initials
Rider initials
F. CONDITIONS OF NATURE – I UNDERSTAND THAT: THIS STABLE IS NOT responsible for total or partial acts, occurrences, or elements of nature that can scare a horse, cause it to fall, or react in some other unsafe way. SOME EXAMPLES ARE: Thunder, lightning, rain, wind, water, wild and domestic animals, insects, reptiles, which may walk, run, or fly near, or bite or sting a horse or person; and irregular footing on out-of-door groomed or wild land which is subject to constant change in condition according to weather, temperature, and natural and man-made changes in landscape.
Parent initials
Rider initials
G. CARRY-ON OBJECTS AND SHARP NOISES – I UNDERSTAND THAT: Riders must not carry loose items on rides which may fall, blow away, flap in the wind, bounce, or make sharp noises, possibly scaring a horse. SOME EXAMPLES ARE: Cameras, hats not securely fastened under chin, toys, purses. Riders must not make sharp, loud noises, such as screaming or yelling, which may scare a horse. CELL PHONES ARE NOT ALLOWED AROUND HORSES
Parent initials
Rider initials
H. SADDLE GIRTHS-NATURAL LOOSENING – I UNDERSTAND THAT: Saddle girths (saddle fasteners around horse’s belly) may loosen during a ride. If a rider notices this he/she must alert the nearest guide or wrangler as quickly as possible so action can be taken to avoid slippage of saddle and a potential fall from the animal.
Parent initials
Rider initials
I. ACCIDENT/MEDICAL INSURANCE – I AGREE THAT: Should emergency medical treatment be required, I and/or my own accident/medical insurance company shall pay for ALL such incurred expenses.
My accident/medical insurance company is *
My policy/group number is *
Parent initials
Rider initials
J. PROTECTIVE HEADGEAR OFFERING: I, for myself and on behalf of my child and/or legal ward, will be offered a SEI CERTIFIED Equestrian Helmet by THIS STABLE and do understand that the wearing of such headgear while mounting, riding, dismounting and otherwise being around horses, may prevent or reduce severity of some of the wearer’s head injuries and possibly prevent the wearer’s death from happening as the result of a fall and other occurrences. It is understood that STABLE-PROVIDED protective headgear may not be of perfect fit for each rider’s head, and that once provided the rider will be responsible for securing the helmet on his/her head at all times.

ALL WHITE PINES RANCH GUESTS MUST WEAR HELMETS – NO EXCEPTIONS
Parent initials
Rider Initials
K. LIABILITY RELEASE – I AGREE THAT: in consideration of THIS STABLE allowing my participation in this activity, under the terms set forth herein, I, the rider, for myself and on behalf of my child and/or legal ward, heirs, administrators, personal representatives or assigns, do agree to hold harmless, release, and discharge THIS STABLE, it’s owners, agents, employees, officers, directors, representatives, assigns, members, owners of premises and trails, affiliated organizations, Insurers, and others acting on its behalf (hereinafter, collectively referred to as “ASSOCIATES”), of and from all claims, demands, causes of action and legal liability, whether the same be known or unknown, anticipated or unanticipated, due to THIS STABLE’S and/or ITS ASSOCIATES ordinary negligence; and I do further agree that except in the event of THIS STABLE’S gross and willful negligence, I shall bring no claims, demands, actions and causes of action, and/or litigation, against THIS STABLE and ITS ASSOCIATES as stated above in this clause, for any economic and non-economic losses due to bodily injury, death, property damage, sustained by me and/or my minor child and/or legal ward in relation to the premises and operations of THIS STABLE, to include while riding, handling or other wise being near horses owned by or in the care, custody and control of THIS STABLE, whether on or off the premises of THIS STABLE.
Parent initials
Rider Initials
All Riders and parents or Legal Guardians must sign below after reading this entire document.

SIGNER STATEMENT OF AWARENESS

I/WE, THE UNDERSIGNED, HAVE READ AND DO UNDERSTAND THE FOREGOING AGREEEMENT, WARNINGS, RELEASE AND ASSUMPTION OF RISK. I/WE FURTHER ATTEST THAT ALL FACTS RELATING TO THE APPLICANT'S PHYSICAL CONDITION, EXPERIENCE, AND AGE ARE TRUE AND ACCURATE
Signature of Rider *
Date *

- Month - Day Year
Signature of Parent
Date

- Month - Day Year

Address in full *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty:

FAMILY WEEKEND EMERGENCY INFORMATION AND LIABILITY RELEASE

LITTLE SISTERS INCORPORATED DBA

WHITE PINES RANCH, 3581 PINES RD., OREGON IL 61061

PHONE: 815-732-7923 FAX: 815-732-7924 WWW.WHITEPINESRANCH.COM

In case of an emergency please contact: