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| "Gator & Howard" |
ROUSH PERFORMANCE HORSES REGISTRATION FORM
Rider’s Name:_____________________________________ Phone: ( ) ____ - _____
Address:___________________________________________________________ Zip:__________
Age/Birth date of Rider: ____/____/____
Riding Experience: (check one) none______ 1-3 yrs _____4-10 yrs_____11 plus yrs
MEDICAL STATEMENT FOR PARTICIPATION IN HORSEMANSHIP ACTIVITIES
I hereby certify that (I am) (he/she is) not under the influence of alcohol or drugs or under treatment for any physical
infirmity or chronic ailment, or injury of any nature and the (I have) (he/she has) normal vision or have/has been
treated for any of the following:
1. Cardiac or pulmonary condition or disease
2. High or low blood pressure
3. Nervous disorders
4. Fainting spells or convulsions
5. Diabetes
6. Respiratory ailments
7. Kidney or related diseases
Parent/Guardian Signature: Date:
HOLD HARMLESS AGREEMENT
Read and initial each section:
I (print name)__________________________________________ am aware that Horsemanship activities may be
hazardous activities, and I am voluntarily participating and/or allowing my dependants to participate in the activities
with knowledge of the dangers involved and HEREBY ACCEPT ANY AND ALL RISKS OF INJURY OR DEATH.
In addition, I HEREBY INDEMNIFY, RELEASE, AND DISCHARGE Roush Performance Horses, Property Owner, and
the Officers, Directors, Employees, and Authorized Agents thereof, and each of them, from all actions, claims or
demands I, my heirs, distributes, Guardians, legal representatives, or assigns now have, or may hereafter have for
injury or damage resulting from participation in horsemanship activities.
Sign and Date:_____________________________________
Signature of Parent/Guardian ___________________________________________________ Date___________
Signature of Participant_________________________________________________________Date___________
Rider’s Name:_____________________________________ Phone: ( ) ____ - _____
Address:___________________________________________________________ Zip:__________
Age/Birth date of Rider: ____/____/____
Riding Experience: (check one) none______ 1-3 yrs _____4-10 yrs_____11 plus yrs
MEDICAL STATEMENT FOR PARTICIPATION IN HORSEMANSHIP ACTIVITIES
I hereby certify that (I am) (he/she is) not under the influence of alcohol or drugs or under treatment for any physical
infirmity or chronic ailment, or injury of any nature and the (I have) (he/she has) normal vision or have/has been
treated for any of the following:
1. Cardiac or pulmonary condition or disease
2. High or low blood pressure
3. Nervous disorders
4. Fainting spells or convulsions
5. Diabetes
6. Respiratory ailments
7. Kidney or related diseases
Parent/Guardian Signature: Date:
HOLD HARMLESS AGREEMENT
Read and initial each section:
I (print name)__________________________________________ am aware that Horsemanship activities may be
hazardous activities, and I am voluntarily participating and/or allowing my dependants to participate in the activities
with knowledge of the dangers involved and HEREBY ACCEPT ANY AND ALL RISKS OF INJURY OR DEATH.
In addition, I HEREBY INDEMNIFY, RELEASE, AND DISCHARGE Roush Performance Horses, Property Owner, and
the Officers, Directors, Employees, and Authorized Agents thereof, and each of them, from all actions, claims or
demands I, my heirs, distributes, Guardians, legal representatives, or assigns now have, or may hereafter have for
injury or damage resulting from participation in horsemanship activities.
Sign and Date:_____________________________________
Signature of Parent/Guardian ___________________________________________________ Date___________
Signature of Participant_________________________________________________________Date___________
| HOLD HARMLESS AGREEMENT |