Insurance Release Form & assumption of risk agreement
Can-Do-It Farm Summer Riding Camp programs 2011
All riding & non-riding participants must read, understand and sign form below. Riders under 18 yrs old must have the signature of BOTH biological parents.(plus own) (Groups may copy form)
I agree to ride at my own risk and carry insurance for myself, my camper, and family
Resident Campers of Can-Do-It Farm: Each camper must be listed on reverse side, and both parents (biological) must sign for the listed camper. Please read and understand this form.
I take full responsibility for and am willing to have the below listed rider(s) engage in horseback riding activities including, but not limited to, trail riding, day camp, lessons, overnight camping and girl/boy scout riding sessions. In consideration of the acceptance by the CDI Horse Farm, of this application to participate in a riding activity at the Farm, which includes the use of Can-Do-It Farm property, I hereby release discharge and hold harmless the Can-Do-It Farm, its’ agents, employees, officers, instructors, counselors, assistant counselors, and owners from any and all claims, demands, actions, damages losses, judgments, and executions which I ever had, now have, or may have or claim to have in the future against the Farm, its’ agents, employees, counselors, and assistant counselors and owners for all personal injuries, known or unknown and injuries to property, real or personal, caused by or arising out of the use of such property or participation in said program, whether such injury or damage may have been caused or is alleged to have been caused, directly or indirectly, by an act of omission, or commission, negligent or otherwise, of the Can-Do-It Farm and its’ employees, counselors, assistants or owners. I hereby agree to indemnify the Can-Do-It (CDI) Farm, its’ employees, counselors assistants or owners, for all damages, liabilities losses, judgments and executions which may be sustained as a result of any injury to myself, child, horse, or any injury to another caused directly or indirectly by the above. By signing this agreement, I agree to carry my own health, life and liability insurance to cover any accident my camper/student/participant may have. I agree to wear protective, approved headgear while riding, (provided helmets may not be a perfect fit for each participant) and ride at my own risk. If you are pregnant, or think you may be, we advise you not to ride horses. ( If you are disabled in any way (physical or mental), this must be made known to CDI Farm owners and instructors. The decision to participate must be made by the Owners and instructors of the Can-Do-It Farm. )
‘INHERENT RISK OF AN EQUINE ACTIVITY” pursuant to Ohio Revised Code 2305.321, means a danger or condition that is an integral part of an equine activity, including, but not limited to, any of the following:
A.) the propensity of an equine to behave in ways that may result in injury, death, or loss to persons on or around the equine. B.) The unpredictability of an equine’s reaction to sounds, sudden movement, unfamiliar objects, persons, or other animals; C.) Hazards, including, but not limited to, surface or subsurface conditions; D) A collision with another equine, another animal, a person, or an object. E.) The potential of an equine activity participant to act in a negligent manner that may contribute to injury, death, or loss to the person of the participant or to other persons, including, but not limited to, failing to maintain control over an equine or failing to act within the ability of the participant.
BOTH BIOLOGICAL PARENTS MUST SIGN BELOW. DO NOT TEAR OFF PARTS OF THIS FORM. FILL ALL INFORMATION IN CLEARLY AND CAREFULLY. FILL IN REVERSE SIDE OF THIS FORM AND ATTACH IF PRINTED INDIVIDUALLY. IF PARENT IS RECEIVING CHILD SUPPORT FOR RIDING STUDENT, SIGNATURE IS REQUIRED. IF ONE PARENT IS DECEASED, PLEASE MAKE NOTE ON THE LINE BELOW. QUESTIONS? 440-858-2244 CANDY STOKES,
*note: if both signatures are not present, you must explain why below the signature….
I agree to carry my own insurance to cover my daughter/son/or self in case of accident, injury, or death.
Signature: Mother X_______________________________________________ Date: _______________
PARTICIPANT: (13 yrs or older must sign also) ___________________________________
Participant (13 yrs or older must sign also) 2__________________________________
Signature: Father X________________________________________________
I have read and understand the form
*** (note: both signatures are required for riders to participate) Biological
Please proceed to page 2.…*the Farm may refuse programs to any group or individual as needed.
CAN-DO-IT FARM INSURANCE RELEASE FORM 2010 pg 2
Please take the time to fill in this information for riding participants of the Can-Do-It Farm.
Girl Scouts, Resident Campers, Day campers, Riding students, Boarders of Farm, Any participants…(including the family of participants) Pace Riders, visitors, show riders
CAMPERS: Resident campers of Can-Do-It Farm must fill in the form below. Carefully print all information for our records. (Signatures of both parents on other side)
NOTE If you wish to receive information on future camps and scout programs, please list your email very carefully, as mistakes are easily made on email addresses.
Please attach first page if printing copy in two pages.
Participants in the program: (resident camper (s) names printed below please)
1. __________________________________ 3. ________________________________________
2. __________________________________ 4. ________________________________________
Important Phone Numbers for emergency use:
Does rider have any physical or mental conditions that may affect his/her ability to ride a horse? Yes/no
Home: ___-___-___________ work: ___-___-____________ cell: ___-___-____________________
Emergency number in case of accident: _____-_____-_______________ (?______________________)
(please fill out all information…)
E-MAIL ADDRESS: ________________________@ _______________________________________
**weight limit: 200 lbs & under
Note: We are sorry, but CDI is not equipped for special needs riders. Please advise the Farm if rider is handicapped before participation. For safety reasons, riders must not weigh more than 200lbs. All riders who are taking any medications, must advise the Farm/instructor of condition for safety of riders.
Parents, Guardians and adults are required to carry their own Insurance to cover riders and participants in any program on the Farm. The Farm will not insure riders for accidents, injury, or death.
Please fill out a new and updated form each season. This form covers the 2010-2011 season. Do not tear off any section of this form, submit with both pages filled out and signed.
Note: PARENTS MUST CARRY THEIR OWN INSURANCE ON RIDERS !!!!
Students, Campers, Girl Scouts, Boarders, and visitors for 2011
Can-Do-It Farm Summer Riding Camp