BACK IN THE SADDLE HORSE ADOPTION, INC RIDER/VOLUNTEER RELEASE FORM
* THIS FORM MUST BE COMPLETED AND SIGNED BY VOLUNTEERS. PLEASE RETAIN A COPY FOR YOUR REFERENCE. VOLUNTEERS UNDER THE AGE OF 18 MUST ALSO HAVE A PARENT/LEGAL GUARDIAN SIGN AND INITIAL THIS FORM.
Please read each statement below carefully. Initial beside each statement after reading and understanding each statement:
1. I understand that horses are independent living beings with their own minds and as such, can never be entirely predictable. ____________
2. I understand that there are always elements of risk in equestrian activities, including permanent disability or death. I understand that common sense and personal awareness can help reduce these risks. ___________
**A parent/legal guardian MUST also initial above statements if participant is under the age of 18.
I am aware that at all times when on Back in the Saddle Horse Adoption, Inc (BITS) property it is MY RESPONSIBILITY to:
1. Be alert and respectful of horses’ intentions signaled with their ears and eyes and carried out with their teeth and hooves.
2. Speak in a reassuring tone when approaching a horse or horses and avoid sudden movements or noises.
3. Never leave horses unattended with their stall door open, in the stable aisles, while they are cross-tied, or in the riding arena.
4. Always lead horses properly with a lead shank.
5. Always wear appropriate clothing including durable shoes.
6. Pick up and replace tack and equipment I have used in the barn or arena.
7. Know locations of emergency telephones, ambulance and veterinarian’s phone numbers, and farm staff. Know all fire emergency procedures.
8. Never be intoxicated or under the influence of illegal substances in the stable or allow others to do so.
9. Read and obey all posted information and warnings.
10. Comply promptly with all verbal directions of BITS staff and instructors unless I believe that by doing so I will endanger myself, other people, or horses, in which case I will immediately express my opinion to the person involved.
11. Refrain from acting in any manner which may cause or contribute to my injury or the injury of other people or horses.
I am aware that at all times when riding, it is my responsibility to:
1. Never ride alone.
2. Check all equipment and tack including the saddle, girth, straps, bridle, bit and curb strap prior to use for signs of weakness and proper adjustment.
3. Use proper equipment and attire including a regulation hard-hat with a chin harness snugly fastened at all times and boots with heels. I also understand that regulation hard-hats are available for use at BITS and that if I choose not to do so, I am wholly responsible for any consequence of not doing so.
4. Ride in control ONLY on horses rated within my ability level.
5. Be constantly aware of, anticipate, and be able to avoid nearby horses, people, obstacles, natural and man made hazards.
6. Never tailgate and always audibly alert nearby riders and people on the ground in advance of changes in direction or when overtaking anther horse.
I understand that this is only a partial list, and I must be safety conscious and exercise sound judgment AT ALL TIMES. ANYONE found to be endangering themselves, other people, or horses faces immediate revocation of riding privileges WITHOUT EXCEPTION and removal from the premises.
___________________________________________ ________________________________
*PARTICIPANT SIGNATURE DATE
___________________________________________ ________________________________
**PARENT/LEGAL GUARDIAN DATE
*Participant: Defined as any individual who knowingly participates in any BITS activity both on or off BITS property, including lessons, barn labor, farm labor, educational activities, fund raising activities and any other activity at any location sponsored by BITS.
** A parent/legal guardian MUST sign this form if participant is under the age of 18.
EMERGENCY INFORMATION
(PLEASE PRINT)
Participants Name: ________________________________________ Birth date :_________________
Address:_____________________________________City: ____________________________
State:____________________Zip:_________________
Phone Number:________________________________ (work)_________________________ (home)
Parent/Legal Guardian: _________________________________________________
Address:_____________________________________City:_____________________________
State:____________________Zip:___________________
Health Insurance Carrier Policy Number:_________________________________________________
Health Insurance Phone Number:_______________________________________________________
Emergency contact:__________________________________________________________________
Address:____________________________________ City: _____________________________
State:___________________ Zip:___________________
Phone Number:______________________________ (work)___________________________ (home)
Family Physician Phone Number :_______________________________________________
Address:____________________________________ City: __________________________
State:__________________ Zip:____________________
Date of Last Tetanus Shot:___________________________________
Any Special Medical Problems or Allergies:______________________________________________
__________________________________________________________________________________
_____________________________________________ _______________________
PARTICIPANT SIGNATURE DATE
_______________________________________________ ________________________
**PARENT/LEGAL GUARDIAN DATE
** A parent/legal guardian MUST sign this form if participant is under the age of 18.
AUTHORIZATION TO CONSENT TO TREATMENT
To be filled in and signed by adult participant, or parent(s) or legal guardian(s) of minor.
The undersigned participant, ___________________________, and parents or legal guardian of a minor participant whose medical insurance is carried by ____________________________________
Policy number______________, authorizes members of BITS as agent(s), to consent to any x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care deemed advisable and rendered by any licensed physician, licensed emergency medical technician, or surgeon, whether on BITS property, in a remote location in an office or in a licensed hospital. This authorization is given in advance of any required care to empower the agent(s) to give consent for such treatment as the health-care giver may deem advisable. This Authorization shall remain effective indefinitely unless revoked in writing.
__________________________________________ ___________________________
*PARTICIPANT DATE
__________________________________________ ____________________________
**PARENT/LEGAL GUARDIAN DATE
*Participant: Defined as any individual who knowingly participates in any BITS activity both on or off BITS property, including lessons, barn labor, farm labor, educational activities, fund raising activities and any other activity at any location sponsored by BITS.
** A parent/legal guardian MUST sign this form if participant is under the age of 18.
LIABILITY RELEASE
The Undersigned_____________________________________(PRINT NAME), does hereby acknowledge and assumes the risk of participation in any and all horse related activities, including riding, at BITS or in any and all locations where BITS activities take place. He/she does hereby acknowledge that he/she will release, BACK IN THE SADDLE HORSE ADOPTION, INC, its officers, volunteers, instructors, advisors, and/or agents in any location where horse related activities are conducted or horses and/or property are used, of and from all claims which may hereafter develop or accrue to them on account of injury, loss or damage, which may be suffered by said minor or to any property, because of any matter, thing, or condition, negligence or default whatsoever, and they hereby assume and accept the full risk and danger of any hurt, injury or damage which may occur through or by reason of any matter, thing or condition, negligence or default, or any person or persons whatsoever.
It is further agreed and understood that he/she shall maintain in full force and effect, a policy of insurance covering medical treatment and all related costs in the event of an injury to him/her as a result of his/her participation in any and all activities at BACK IN THE SADDLE HORSE ADOPTION, INC as aforesaid. He/she shall also agrees that if he/she does not maintain in full force and effect a policy of insurance, he/she is still liable for medical treatment and all related costs in the event of an injury to him/her as a result of his/her participation in any and all activities involving BACK IN THE SADDLE HORSE ADOPTION, INC as aforesaid. Liability insurance is also strongly urged. He/she hereby agrees to assume all expenses, medical, liability, or otherwise, arising out of any injury to him/her or other individual associated with or while participating in any horse related activity or event either at BACK IN THE SADDLE HORSE ADOPTION, INC. or at a remote location, and understands that BACK IN THE SADDLE HORSE ADOPTION, INC does not provide health, accident, or liability insurance to participants in horse related activities.
The person executing this release acknowledges that there is a valid consideration to executing this release.
The invalidity of any statement or waiver of rights above under local, state or federal law does not invalidate any other statement or waiver of rights above.
________________________________________ _____________________________
*PARTICIPANT DATE
________________________________________ _____________________________
**PARENT/LEGAL GUARDIAN DATE
*Participant: Defined as any individual who knowingly participates in any BITS activity both on or off BITS property, including lessons, barn labor, farm labor, educational activities, fund raising activities and any other activity at any location sponsored by BITS.
** A parent/legal guardian MUST sign this form if participant is under the age of 18.