West Equestrian Camp Page 1
please make sure to mail both forms....mailing address located at the bottom of page 2.
__________________________________________ ________________________________________
Participant name Parent name
___________________________________________________________________________________
Address city state zip
___________________________________________________________________________________
Phone (work) (home) (cell) (pager) (other)
______________________ __________ ______________________________________________
Birth date month/day/year Age Email
Riders Experience____________________________________________________________________
Never been on____ Walk Only______ Pony Rides ______ Summer camp (how many)________
Trots _______ Posting Trot _________ Cantered 1 - 4 times ______ Proficient at all gaits_______
Lessons: English________ Western_______ Jump_______ Dressage_________
None_____1-10hrs lessons______10-50hrs lessons_______50hrs +lessons________
Own horse_____No lessons but ride often______ This info will help put riders of similar ability together.
In case of emergency contact ____________________________________________________________
Name Relationship Phone
Physician and Hospital _________________________________________________________________
Insurance Group Name_________________________________________NO#_____________________
Insured Name________________________________________________ Insured ID#_______________
$50 non refundable deposit required with enrollment.
Make checks payable to West Equestrian.
Remainder must be paid 7 days prior to camp.
Date of camp: _______________
Secondary camp if full: _______________
Medical Release:
I hereby give West Equestrian and its instructors and associates, permission to act as temporary guardian
of________________________________________ from ____________ to ____________(camp date). I hereby
authorize The above mentioned of 5716 Dip Creek Rd. Sand Springs to transport and/or authorize proper
licensed/certified medical personnel to treat injuries and/or illnesses as they deem necessary.
_____________________________ ________________
Signature Guardian/Parent Date
Page 2
Oklahoma Livestock Activities Liability Limitation Act Section 50.1 of Title 76 B. 1. The Oklahoma Legislature
recognizes that persons who engage in livestock activities may incur injuries as a result of the risks involved in such
activities even in the absence of any fault or negligence on the part of persons or entities who sponsor, participate or
organize those activities.
Horse back riding, care of, and exposure to horses, and the use of any horse or horseback riding equipment involves
risk and danger, and/or injury. The behavior of the horse can be unpredictable, and at times based on instinct or
fright, which may cause injury. Horses may bite, kick, buck, lie down, stumble, or fall. Saddles may slip, tack may
loosen, and wear tear may cause tack problems. All efforts will be made to make sure equipment remains
serviceable and safe, but unforeseeable events could occur. Terrain ridden is subject to change, due to weather and
natural causes. Terrain, and obstacle variations could cause loss of control, and, or injury.
Signature of this form admits awareness that this activity entails risks of injury or death. I understand that the
description of these risks is incomplete, and that unknown or unanticipated risks may occur. I agree to assume
responsibility for all identified and unidentified risk factors. My participation in this activity is purely voluntary, and I
elect to participate, despite the previously mentioned risks. I further agree not to hold West Equestrian Services and
Training responsible for any accidents that may occur.
I certify that the I am, or my minors are, fully capable of participating in this activity, and assumes full responsibility for
myself, and minor children, for bodily injury, death, and loss of personal property, and all expenses thereof, as a
result of those inherent risks and dangers, and of any negligence in participating in this activity. I have read this,
agree with it, and have advised my child or ward to obey rules of West Equestrian. I personally carry hospital
insurance on my child or ward and accept this responsibility.
I have read, understood, and accepted the terms and conditions stated herein and acknowledge that this agreement
shall be effective and binding upon myself, my heirs, assigns, personal representative, estate, and for all members of
my family, including minors accompanying me, or participating in anything involved with horses, events, or activities
related to horses, and fund raising both on and off West Equestrian Properties. This agreement will be effective until
written notice by the participant of cancellation of lessons.
_____________________________ ________________
Signature Guardian/Parent Date
Mail To:
West Equestrian C/O Summer Camp
3963 S Hwy 97 #316
Sand Springs OK 74063
For Office Use Only
Camp cost ________
Deposit ________
Early pay discount ________
________
subtotal ________
Amount due _______
Amount paid _______
|
|