Phone: 941-879-3233 | E-Mail: [email protected]

Rider Agreement & Releases Rider Name ______Rider Age: ______If Minor/Parent(s) Name and address where minor child resides: ______If Minor, authorized person(s) who may pick up child: ______Responsible Party for Payment: Name:______Address ______City State Zip Code Email Address ______Physical or medical conditions or other limitations:______Contact Information: Cell/Home/Work Telephone ______Emergency Contact # 1: ______Emergency Contact # 2: ______****If minor: Parents Names ______Mom’s Work/Cell/Home Number______Dad’s Work/Cell/Home Number ______

Page 1 of 4 Rev: 1/19/15 ______(INITIAL) PAYMENT OPTIONS: Cash ______Check*_____ (*Insufficient funds will incur reimbursement for any bank fees.) Credit Card: ______Name on Card: ______Card # ______Exp. Date:_____ CVS: ______AMOUNT: ______Description: ______Horse Camps will require a separate Application and fee arrangement.

EXPERIENCE: What do you think your child’s riding level is? (Circle One) Very Beginner Beginner Intermediate Advanced

Tell us about your prior experiences with horses: ______

LIABILITY RELEASE WARNING: UNDER FLORIDA LAW, AN EQUINE ACTIVITY SPONSOR OR EQUINE PROFESSIONAL IS NOT LIABLE FOR AN INJURY TO, OR THE DEATH OF, A PARTICIPANT IN EQUINE ACTIVITIES RESULTING FROM THE INHERENT RISKS OF EQUINE ACTIVITIES. IN SIGNING THIS WAIVER, I, THE PARENT/GUARDIAN ASSUME THE INHERENT RISKS INVOLVED.

WAIVER: I, THE UNDERSIGNED, REALIZE THAT THERE IS A RISK OF BODILY INJURY WHILE PARTICIPATING IN ANY SPORT. I UNDERSTAND THAT A HORSE CAN NEVER BE ENTIRELY PREDICTABLE. I AM AWARE THAT THE SHEER SIZE AND THE WEIGHT OF HORSES MAKES WORKING AROUND THEM A PARTICULARLY RISKY SPORT TO CHOOSE. AS IN ANY SPORT I CHOOSE TO LEARN, I REALIZE THAT IT IS MY RESPONSIBILITY TO LEARN SAFE PRACTICES WITHIN THE SPORT AND FOLLOW THE DIRECTIONS AND HEED CAUTIONS WHENEVER I PARTICIPATE IN THAT SPORT. I AM PREPARED NOW, AND IN THE FUTURE, TO ACCEPT RESPONSIBILITY FOR ALL OF THE RISK OF PERSONAL INJURY OR DEATH THAT IS POSSIBLE AS I LEARN TO HANDLE AND RIDE A HORSE. I WOULD ACTIVELY PURSUE HORSEBACK RIDING LESSONS ELSEWHERE IF I DID NOT RECEIVE INSTRUCTION HERE.

Page 2 of 4 Rev: 1/19/15 ______(INITIAL) I UNDERSTAND THAT I AM WAIVING ALL MY RIGHTS TO A LAWSUIT RESULTING FROM ANY ACT, INCLUDING BUT NOT LIMITED TO, NEGLIGENCE ON THE PART OF THE INSTRUCTOR, THE OWNERS, OR THEIR EMPLOYEES, TRUSTEES OR REPRESENTATIVES THAT RESULTS IN MY OWN INJURY OR DEATH. I ALSO REQUEST THAT MY HEIRS, REPRESENTATIVES AND DEPENDENTS REFRAIN FROM BRINGING FORTH A LAWSUIT ON MY BEHALF, OR FOR THEMSELVES, FOR I CHOOSE TO ASSUME RESPONSIBILITY FOR MY RISK IN THIS SPORT. I AUTHORIZE THE INSTRUCTOR TO SUMMON PROFESSIONAL EMERGENCY MEDICAL TRANSPORTATION FOR THE PURPOSE OF TRANSPORTING ME TO A MEDICAL FACILITY IN THE EVENT OF INJURY.

CERTIFIED ASTM/SEI HELMET REQUIREMENT OR LIABILITY RELEASE This Facility takes great care and places a high value on safety. Therefore, our policy is to require all MINORS to own and wear at all times whether on or off the property while around horses an ASTM/SEI Certified Helmet. No exceptions. Bike helmets are not designed for horse activities and will not be permitted. Helmets should be put on upon entering the Facility or other area where horses will be. No rider may ride without wearing a helmet while participating in an equine related activity, and by way of explanation and not limitation includes riding, grooming, walking in any area where a horse may be located or moved to include the barn, wash racks, arenas, paddocks, pastures, turn outs or any open areas. I also understand that if I am an adult (non-minor) I may choose for myself only not to wear a helmet and I understand and accept the inherent danger of this decision. _____I am an adult non-minor (18 yrs and older) and I choose not to wear a helmet.

PHOTO RELEASE ______I give permission for photos of myself or my minor child to be taken during horseback riding with High Voltage Acres, Inc (HVA) which may be reproduced in advertisements promoting HVA’s in magazines, newspapers and on HVA’s Facebook, and Website. ______No, I do not give permission for photos of myself or my minor child’s photos to be used.

LESSON CANCELLATION POLICY Hi Voltage Acres, Inc.’s cancellation policy is 24 hrs. advanced notice (or as soon as reasonably possible as we understand emergencies do occur). You have been provided our email and phone numbers and we check messages regularly so your courtesy in this regard is both appreciated and required. Since our instructors are paid by the lesson, if we do not receive a call promptly canceling your scheduled lesson you will be billed for one-half of the cost of the lesson in order to reimburse the instructor for the time he/she was scheduled for your lesson. If there are two

Page 3 of 4 Rev: 1/19/15 ______(INITIAL) unexcused no-shows or late notices of cancellation, we reserve the right to schedule another lesson in your timeslot or we may discontinue lessons.

EMERGENCY MEDICAL PERMISSION A copy of your medical insurance card may be kept on file at our request. I, ______, participant or parent/guardian of ______participating in horseback riding with Hi Voltage Acres, Inc. hereby consent to any medical, dental or surgical treatment or procedure of an emergency nature that is reasonable and necessary to address said emergency to include saving my life or the life of my minor child. Name & address of Insurance: ______Policy Number: ______I understand and consent that should medical emergency treatment be required, the current insurance listed will be provided to the attending hospital or medical provider to cover future payment of incurred bills and any financial obligation resulting from any such treatment or care shall be at my sole expense. Allergies ______Physical or medical conditions or other limitations:______#1 Emergency Name & Phone No. ______Relationship: ______#2 Emergency Name & Phone No. ______Relationship: ______I HAVE READ AND UNDERSTAND ALL INFORMATION IN THIS DOCUMENT .

______Date______Signature of Participant or Legal Guardian if minor

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