R.R.#2 – 1145 Bradley Road
Chelmsford, ON P0M 1L0
Tel: (705) 855-5818
info@bhranch.ca
Liability Release Form
Rider Personal Information:
Name:
_____________________________________________
Date of Birth: _____________________________________________ (if junior)
Address:
_____________________________________________
_____________________________________________
_____________________________________________
Email:
_____________________________________________
Tel:
__________________________ (home)
__________________________ (work)
Known medical problems: ___________________________________
Under any medication:
___________________________________
Emergency Contact Info:
Name:
______________________________________________
Relationship: ______________________________________________
Tel:
___________________________ (home)
___________________________ (work)
Doctor:
______________________________________________
**All riders will be required to pay in full any lesson that has not been cancelled at
least 48 hours in advance.