Eliza S Helping Hands, Inc

ELIZA’S HELPING HANDS, INC

RIDING FOR POWER APPLICATION

APPLICATIONFORENROLLMENTANDLESSONCONTRACT

I WISHTOENROLLFORLESSONS (PRINT FULLNAME)

HOWDIDYOUHEARABOUTPROGRAM?

YellowPages Internet Friends CampPrograms ParkRec. Other

Pleasespecify

INORDERTOASSIGNYOUAHORSEANDSADDLE,PLEASEGIVE:

AGE HEIGHT WEIGHT SHOESIZE BIRTHDAY(Ifunder18)

1225 EAST 5TH STREET, WINSTON SALEM, NC 27101

P (336) 776-0322

ELIZA’S HELPING HANDS, INC

RIDING FOR POWER APPLICATION

INITIAL DATE

RIDER’SCONTACTINFORMATION:

(PLEASEREMEMBERTOKEEPUSUPTODATEONHOWTOREACHYOU)

HOMEADDRESS:CITY: ZIPCODE:

HOMEPHONE: WORK/CELLPHONE: E-MAIL: FAX: EMPLOYER: RIDER’S HISTORY:

Howmanyyearshaveyoubeenridingregularly?

Whatstylesandtypesofridinghaveyoudoneinthepast?(e.g.,Dressage,Trail Rides,Westernpleasure, Hunter/jumper) IF RIDERISOVER18,PLEASESIGNHERE: IF RIDERISUNDER18,PARENTSIGNATUREHERE: PRINTPARENTSNAMEPLEASE:

1225 EAST 5TH STREET, WINSTON SALEM, NC 27101

P (336) 776-0322

ELIZA’S HELPING HANDS, INC

RIDING FOR POWER APPLICATION

EMERGENCYMEDICALINFORMATION

PRIMARYCAREPHYSICIAN: PHONE: INSURANCE CARRIER: POLICY#: NAME OFPOLICYHOLDER: RELATIONTOPATIENT: PREFERREDHOSPITAL: (In caseofemergency)

Doesthisrider haveanydisabilities,presentinjuries,healthlimitations,ormedicalconditions?

(circle)

Yes No

IfYes,please clarify

Eliza;s Helping Hands, mustbeadvisedifclient hasanysignificantmedicalorphysicalconditioni.e.fainting spells,seizuresetc.that wouldaffectthisrider’sabilities ona horse.

PERSONSTOCONTACTINANEMERGENCY

Home: Cell: Work:

Home: Cell: Work:

ADULTCONSENTFORM(RIDERS18OVER)

I ,doherebygivemyconsenttoEliza’s Helping Hands, Incandanyofit’semployeesorrepresentativestohavemyselftreated

by anyphysicianorsurgeonincaseofsuddenillnessorinjurywhilewithEliza’s Helping Hands, Inc

X

MINORCONSENTFORM(RIDERSUNDER18)

I, ,doherebygivemyconsentto Eliza;s Helping Hands, Incandanyofit’semployeesorrepresentativestohavemy childtreated by anyphysicianorsurgeonincaseofsuddenillnessorinjurywhilewith Eliza’s Helping Hands, staff, volunteers or representatives.

X

1225 EAST 5TH STREET, WINSTON SALEM, NC 27101

P (336) 776-0322

THISDOCUMENTLIMITSOURLEGALLIABILITY PLEASEREADIT

WhyHorsesCanBeDangerous

Domesticated,well-trainedhorsesareusuallyobedient,docileandaffectionate.However,theyare instinctively“flightanimals,”andtheirnaturalinstinctsandsizecanbedangeroustopeople.For example:

1.Horsesareunpredictable,withmindsoftheirown,andtheyareoftensomewhathigh strungornervous.

2.Horsesareverystrongandpowerful,andtheyareextremelyheavy,weighingfrom600 to1300poundsonaverage.

3. Whenahorseisfrightened,stressedorfeelsthreatened,itmay:

Suddenlyjumpforwardorsideways,knockingdownorrunningintopeopleor obstacles.

Runawayatspeedsupto35milesperhour.

Buckorrearupinawaythatcouldthrowaridertothegroundorintoan obstacle.

Biteorkick.

SafeBehaviorAroundHorses

Tohelppreventinjuriesand/ordeath,Iagreetofollowcarefullyallinstructionsgiventomeby SpringDownregardinghorsebehaviorandhandling.IagreetofollowcarefullyallSpringDown rulesandtousetackandotherequipmentonlyasdirectedbySpringDown.

SafetyAttire

Whileinvolvedinhorse-relatedactivities,Iagreetowearthefollowingsafetyequipmenttohelp preventinjuriesand/ordeath.

A properlyfittedASTMcertifiedhelmetfastenedsecurelyunderthechin.IfIdonothavea helmet,IcanaskSpringDownto provideoneforme.

Hard-soled,low-heeledshoesorboots.

Glovesdesignedforriding.

Longpantsandshirtswithlongsleeves.

Release,HoldHarmlessandIndemnificationAgreement

Iunderstandthathorse-relatedactivitiesareinherentlydangerousandIexpresslyassumetherisks associatedwithworking with Eliza;s Helping Hands.Iunderstandthathorsesareinherentlyunpredictableanimals andeventhemostdocilehorse(“horses”includesponies)mayoccasionallybolt,spook,buck,rear, bite,kick,pullbackorotherwiseactinsucha waythatmayinjuremeorothers.Iexpresslyassume allrisksofworking withEliza’s Helping Hands, Incandengaginginhorse-relatedactivitiesthrough Cashlovell Stables, includingtherisk

Accordingly,Iagreeuponbehalfofmyself,myheirs,guardiansandlegal representatives,nottosueEliza’s Helping Hands,orotherwisemakea claimagainstEliza’s Helping Hands or its board members, staff or volunteers,andIreleaseEliza’s Helping Hands, Inc,inconnectionwithanyinjuryordeath occurringwith Eliza’s Helping Hands, or premisesorinconnectionwithanyof Eliza’sactivities,orin connectionwithanydamagetoorlossof personalproperty.Inaddition,Iwilldefend,indemnify andholdEliza’s Helping Hands, Incharmlessagainstallclaims,demands,andcausesofaction, includingwithoutlimitationcourtcostsandattorneys’fees,directlyorindirectlyarisingfromany actionorotherproceedingsbroughtbyorprosecutedformybenefit.Thisreleaseandholdharmless shallapplywhetherthemattertowhichitappliesarisesundercontract,tort,(includingactiveor passivenegligenceofEliza’s Helping Hands, Inc)orotherwise.

WaiverofUnknownClaims

IexpresslywaiveanybenefitsImayhaveundersectionNorth CarolinaCivilCoderelating tothereleaseof unknownclaims:

“Ageneralreleasedoesnotextendtoclaimswhichthecreditordoesnotknoworsuspectto

existinhisorherfavoratthetimeofexecutingtherelease,whichif knownbyhimorher musthavemateriallyaffectedhis orhersettlementwiththedebtor.”

ReleaseandHoldHarmlessAgreementforParentsorGuardians

Wearethelawfulparentsorguardiansof (nameofchild)and havealllegalrightstosignthisagreementon behalfof ourchildandourselves.Accordingly,we havereviewedtherisksthatourchildwillbeundertakinginvisitingCashlovell Stablesand Parnter Eliza;s Helping Hands, Inc engagingin horse-relatedactivitiesthroughCashlovell Stables or Eliza;s Helping Hands, Inc,includingtheriskofnegligence.Personalproperty with Eliza;s Helping Hands, or on the premises,includingautomobiles,issubjecttotheft,damageorloss.We expresslyagree,onbehalfofourselves,ourchild,ourchild’sheirsandlegalrepresentativesto assumetheserisksandnottosuetheEliza’S Helping Hands, Cashlovell Stables, and Community Interventionorotherwisemakeaclaimagainstsuch parties,andwereleasetheEliza’s Helping Hands, IncParties,inconnectionwithanyinjuryordeathoccurring withEliza’s Helping Hands, Inc or Community InterventionpremisesorinconnectionwithanyEliza;s Helping Hands Inc,activities,orinconnection withanydamagetoorlossof personalproperty.Inaddition,wewilldefend,indemnifyandhold Eliza’s Helping Hands, Incharmlessagainstallclaims,demands,andcausesofaction,including courtcostsandattorneys’fees,directlyorindirectlyarisingfromanyactionor otherproceedingsbroughtby or prosecutedfor ourbenefitor ourchild’sbenefit.Thisreleaseandholdharmlessshall applywhetherthemattertowhichit appliesarisesundercontract,tort,(includingactiveorpassive negligenceof Eliza’s Helping Hands, Inc)orotherwise.

Date: , 20 .

RiderIFOVER18:

Signature

(print):

ParentsIFRIDERUNDER18:

Signature

(print):