Form 511 State of Oklahoma by rke15301


More Info
									                                      WE        est     questrian S   ervices

                                                            and   T   raining

                                                                                  Horsemanship Clinic
                                                                                     Registration form

Clinic Location: ____Blue Stem Therapeutic___ 511 County Rd 3007, Bartlesville 74003 _____
Clinic Date _______October 18, 2009________
Rider/Handler over 18 yrs of age? _______
Name: ______________________________________________________
Address: _____________________________________ City: ______________ State _____ Zip _________
Phone: (Home) ____________________ (Work) _____________________ (Cell) ____________________
Email address: ______________________________
Emergency Contact (Name): ____________________________________ (Phone) ___________________
Where did you hear about this clinic? ________________________________________________
Name of horse: _________________________________________ Age of horse: _____________
Gender of horse: _____________ Breed of horse: _______________ Color: _________________
Any Horse Health Concerns: _______________________________________________________
Previous training: ________________________________________________________________
Problem areas: __________________________________________________________________
Future plans for this horse: _______________________________________________________
Training goals: __________________________________________________________________
Questions or issues you would like addressed at this clinic: ______________________________
Recommended What to Bring: Lawn chair, Note pad and pen, all horse tack for participants:
snaffle bit , Rope halter with a minimum 12-foot lead, Helmets are recommended, Current Negative
Coggins required for participating horses, No dogs or alcoholic beverages please.

Participant/Rider                                                                   ___85.00____ X _____________
After clinic private session                                                        __($40/hour) ___ X _____________
Auditor/Spectator                                               1 person            __15.00_____ X ____________
                                                            Family (2+ )            __10.00_____ X ____________

                                                                       GRAND TOTAL OF ABOVE $______________

30.00 non-refundable deposit for all except spectators                           Check No. __________ Cash _____
                                                            .                  MINUS DEPOSIT <______________>

                                                                          TOTAL DUE AT CLINIC $______________
Make checks payable to “W.E.S.T.”Balance due upon arrival.

RELEASE and WAIVER Under Oklahoma Livestock Activities Liability Limitation Act Section 50.1 of Title 76 B. 1.
The Oklahoma Legislature recognizes that persons who engage in livestock activities may incur injuries as a result of
the risks involved in such activities even in the absence of any fault or negligence on the part of persons or entities
who sponsor, participate or organize those activities. While every effort is made to ensure a safe, enjoyable
experience, horseback riding and all the activities therein are not experienced without some risk. In consideration of,
and as part payment for, the right to participate in such horse activities I hereby assume as my personal risk all the
hazards and dangers of horseback riding and all associated activities. I release Blue Stem and any associated
employees and/or volunteers and staff, Cheryl West, and any associated with West Equestrian Services and Training
from any liability of any kind for injury or damage which may befall me or my property while I am participating in this
horse activity.

Signature of Participant ____________________________________________________
Horse Owner or Agent _____________________________________________________
Guardian for Minor ________________________________________________________
If you have any questions please contact us by email us
at or call918 363 7610.

Authorization for Emergency Medical Treatment
Name:_____________________________________________ DOB: ___/___/___ Phone:_________________
Address:__________________________________________ City:_______________State:_____ Zip:_______
Physicians’s Name:______________________________Medical Facility:______________________________
Health Insurance Company:___________________________________________________________________
Allergies to Medications:______________________________________________________________-_______
Current Medications:_________________________________________________________________________
In the event of an emergency, contact:
        Name:___________________________Relationship:_____________ Phone:________________
        Name:___________________________Relationship:_____________ Phone:________________

In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving
services, I authorize W.E.S.T. to:
          1. Secure and retain medical treatment and transportation if needed.
         2. Release client records upon request to the authorized individual or agency involved in the medical
         emergency treatment.

Consent Plan
This authorization includes x-rays, surgery, hospitalization, medication, and any treatment procedure deemed
“lifesaving” by the physician. This provision will only be invoked if the person(s) above cannot be reached.
Date:___________ Consent Signature:_______________________________________________
                                                          Client, Parent, or Legal Guardian

Non-Consent Plan
I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of
receiving services. In the event emergency treatment/aid is required, I wish the following procedures to take place:

Date:_____________ Consent Signature:_____________________________________________
                                                Client, Parent, or Legal Guardian

Helmet Release
It is highly recommended that participants use helmets, and require that use for anyone under the age of 18. Under
request, W.E.S.T. or associated facilities will provide certified helmets. I, for myself, have been fully warned and
advised by Cheryl West of W.E.S.T., Inc (hereafter “Clinician”) that I should wear property fitted and secured ASTM-
Standard/SEI-certified protective headgear that is designed for use by equestrians when riding any equine breed in
order to reduce the severity of some head injuries and possibly prevent death from happening as the result of a fall or
other occurrences. I am not relying on the Clinician or anyone affiliated with Clinician to provide a certified equestrian
helmet or headgear for me, to check any helmet or strap that I may wear, or to monitor my compliance with this
suggestion at any time – now or in the future. If I choose to wear an ASTM-Standard/SEI certified helmet and
headgear, or if I choose not to, this is my decision alone.
Signature of

To top