Student Name:__________________________________________________________________________________________

Street Address:_________________________________________________________________________________________

City: __________________________________________State:___________________Zip:_____________________________

Age:________________________________Date of Birth if under 21____________________________________________

Home Phone:_____________________________Guardian Work Phone:_________________________________________

Cell Phone:_________________________________Other:_______________________________________________________

I would classify my riding ability as one of the following:

_____Beginner _____Advanced Beginner _____Intermediate _____Advanced

Signed:________________________________________________________Date:__________________________________

If under 18, signature of parent or guardian is required

For the safety of the rider, it is essential that we know about any physical, mental or emotional conditions we should take into consideration in our instruction of this student.

 Please be thorough in explaining condition below:

The undersigned assumes the unavoidable risks inherent in all horse-related activities, including but not limited to bodily injury and physical harm to horse, rider, spectator and damage to

 personal property, illness, bodily injury, trauma or death resulting from a fall or while riding or being in close proximity to horses. The undersigned does hereby agree to hold harmless 

and indemnify BC National Banks, Peculiar, Mo and R & R Stables and either organization’s successors, assigns and employees, and further releases them from any liability or 

responsibility for accident, damage, injury, illness or death to the undersigned or to any

 property or horse owned by the undersigned or to any family member or spectator accompanying the undersigned on the BC National Banks premises.

NOTICE: An equine professional is not liable for an injury or death of a participant in equine activities resulting from the inherent risks of equine activities pursuant to 

the revised statutes of Missouri.

The undersigned parent(s) of the above named student, a minor, hereby consent(s) that said minor

may participate in the teaching and training program of BC National Banks and R & R Stables. By signing below, the Undersigned agrees to the above, and releases

 BC National Banks, R & R Stables their assigns, insurer, employees and contractors from all liability for any injury that may occur to said minor during the course thereof.

 We agree to indemnify and hold harmless BC National Banks & R Stables for any and all claims and demands that might or could be made by, 

Parent/Legal Guardian Signature:__________________________________________Date:_______________________

Please print name:_____________________________________________________________________________________

****************************************************

Enjoy  riding lessons, horsemanship and craft activities

Student’s Physician:

Name:__________________________________________________________________Phone No;________________________

If the above physician is not available , we consent to have the emergency room physician treat our child

___________yes _____________no

Responsible person other than guardian to contact in event of emergency:

Name:___________________________________________________________________Phone No:_______________________

Additional Phone No:_____________________________________________________________________________________

Address:_________________________________________________________________________________________________

Student’s Medical Information:

Allergies:________________________________________________________________________________________________

Current Medications:_____________________________________________________________________________________

Date of last Tetanus (Lockjaw) immunization: ____________________________________________________________

Health Insurance Information:

Company Name:______________________________________________Insured’s Name:____________________________

Policy Number:________________________________________________Group Number_____________________________

Parent/Guardian’s Signature:_________________________________________________Date:_______________________

All Information confidential to R & R Stables