August 23, 20089
To Benefit the Springfield Humane Society
REGISTRATION FORM:
Name:____________________________________ Horse’s Name_________________________
Address:______________________City:_______________________State_______Zip:_________
Tel:____________________________email:_____________________________________________
INDIVIDUAL AGREEMENT AND WAIVER OF
LIABILITY WARNING
Under
resulting from the inherent risks of equine
activities that are obvious and necessary, pursuant to 12 V.S.A. section 1039.
understand that the sport of horseback riding
and driving is inherently dangerous and that serious injury and death can
occur. I understand that participation in
equine activities involves necessary risks. I agree that if any injury occurs
to my
horse or myself or to any equipment
that I may use or send to use, I will make no claim against the CHAPSS Riding
Club or any of the Officers, Directors, Trustees, Employees and Volunteers. I
further agree to hold the CHAPS Riding Club, the Officers, Directors, Trustees,
Employees, Volunteers and Landowners free and harmless from any liability,
claims, suits or damages of whatsoever kind or nature that may be occasioned by
the horses used by me or the negligence of the persons in charge of such horses
and I agree to indemnify and hold harmless this organization and individuals
against all liability claims, suits, and expenses including attorney fees
incurred arising out of any injury to any person or damage to any property
caused by me, my horses or attendants.
Helmet release (Helmet
REQUIRED for anyone under 18 years of age):
I acknowledge that wearing a properly
fitted and secured helmet while riding, mounting, dismounting and being near
horses may reduce the severity of head injuries or prevent death occurring as
the result of a fall or other occurrence. I assume all helmet related risks,
including but not limited to the risk of injury if I do not wear such a helmet.
______________________________________________________
SIGNATURE OF RIDER
______________________________________________________
SIGNATURE OF HORSE OWNER
______________________________________________________
SIGNATURE OF PARENT/GUARDIAN
(REQUIRED FOR JUNIOR RIDERS UNDER 18)
Send to: Dorothy Andrews Or Fax to: Karin Lewis
803 Parker Hill Road 802-885-9444
Springfield, VT 05156