Fillable Safety Equipment Acknowledgment And Release Form (Page 2 of 2) in pdf

SAFETY EQUIPMENT ACKNOWLEDGMENT AND RELEASE FORM

For Participants Under the Age of Majority

(

)

Please Print Clearly

Infant Participant's Name:______________________________________ Date of Birth:_______________

Infant's Address:_______________________________ City________________ Prov.____ Postal_______

Parent/Guardian Name:________________________________________ Date of Birth:_______________

Parent/Guardian Address:_________________________City_______________ Prov.____ Postal_______

No person riding without a helmet designed for equine activities will be allowed to participate

in equine activities prior to reading and signing this form.

Parent/Guardian must Read and Understand prior to the Infant Participating in Equine Activities

TO:_________________________________________________________________________________,

their directors, employees, (Name of Person, Organization or Company providing the Equine Activities)

officers, volunteers, business operators, and site property owners, (all of them collectively called the HOST):

ACKNOWLEDGMENTS AND STATEMENTS OF PARENT/GUARDIAN

Initial each item below After Reading and Understanding the item.

_____ 1) I am the Parent or Legal Guardian of the infant Participant named above and am executing

this form on behalf of the infant Participant in my capacity as parent or guardian with the intent

this Form Is To Be Binding on Myself and the Infant Participant for All Legal Purposes.

_____ 2) I Understand the RISKS inherent in equine activities as evidenced by the separately signed

Acknowledgment of Risk and Release of Liability Form on file with the "Host".

_____ 3) I Understand injury may be reduced by wearing proper safety equipment and that no amount

of preplanning can remove all the DANGERS, HAZARDS, and RISKS of equine activities.

_____ 4) I have Freely Decided to allow the infant Participant to ride without wearing a helmet designed

for equine activities which might prevent permanent brain damage in the event of an accident.

_____ 5) I have Permitted the Refusal of Critical Safety Equipment against the advice of the "Host".

_____ 6) I Assume Full Responsibility for all additional DANGERS, HAZARDS, and RISKS of injury

my decision to permit riding without a helmet might expose the infant Participant.

_____ 7) I Agree to HOLD HARMLESS and INDEMNIFY the “Host” from any and all liability for injury

resulting from the infant Participant riding without a helmet designed for equine activities.

_____ 8) I Understand that signing this form Waives certain Legal Rights that I or the infant

Participant might have against the “Host”.

Before signing this form I read it

(as indicated by my initials

above) and I state that I understand it. I

further state I am aware that signing this form, waives certain legal rights I and/or the infant

Participant and/or our "Legal Representatives" might have against the “HOST”.

SIGNED This _______________________ day of _____________________________ , 20____

_______________________________________

(Signature of Parent/Guardian)

Do Not Sign until you Understand All Items Above

________________________________________

______________________________________

(Print HOST Name Witness to Signing & Initialing)

(Signature of HOST Witness)

Safety Equipment Acknowledgment And Release Form Page 2

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