RIDER RELEASE FORM
Please read this document carefully and do not sign it unless you fully understand it.
Student’s Name: ____________________________________ Date of Birth: __________
Address: Street ___________________________________________________________
City: _____________________________________________ Zip: __________
Home Phone: ___________________________Work Phone: ______________________
If under age 18:
Parent/Guardian: _________________________________________________________
Address: Street __________________________________________________________
City: _____________________________________________ Zip:__________
Physician’s Name: ______________________________ Physician’s Phone: __________
Health Insurance Co.: ______________________________ Policy #: _______________
Photo Release:
Please Circle One
I (do/do not )consent to and authorize the use and reproduction by PVTRA for any and all photographs and any other audio-visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.
Student: _________________________________________ Date: ________________
Parent/Guardian _____________________________________ Date: ________________
(If under 18)
Over
Release
I recognize the inherent risks of injury involved in general horseback riding and learning to ride in particular. In taking lessons with the Pioneer Valley Therapeutic Riding Association, Inc. (PVTRA), I assume any such risk of injury. I voluntarily release PVTRA, its instructors, employees and agents from any responsibility on account of any injury I or my child or ward many sustain while receiving instruction or while riding in connection therewith and I agree to indemnify and hold harmless PVTRA, its instructors, employees and agents on account of any such claim.
Parent/Guardian: ________________________________________ Date: ____________
Student: _______________________________________________ Date: ____________
Medical Authorization
In the event that the above-named student requires emergency medical treatment on account of any accident or injury which may occur in connection with any activities with PVTRA, the authorities at PVTRA are hereby given full authorization to provide all such necessary emergency medical treatment for the above-named student including permission for administration of anesthesia.
Parent/Guardian: ____________________________________________ Date: ________
Student: ____________________________________________________Date: ________
In case of an emergency, please contact:
Name: __________________________________________ Telephone: ______________
