2008 Michigan Youth Horse Racing Program
For Official Use Only: Coggins Ok ________ Entry Fee Paid ______ Cash ___ Check#_____ Classification ________ Age Group___________
PARTICIPANT INFORMATION FORM
“Bringing yesterday’s tradition of horse racing back to our youth”
Name: ________________________________________________________________________
Last First MI
Address:_______________________________________________________________________
Street
______________________________________________________________________
City State ZIP
Phone ( ____ ) ______________ Participants Age as of Jan 1: _____
Date of Birth: ____/ ____ / ____
Month Day Year
Grade: ___________
Equines Age: ______
Years Riding Equine:_________
Equines Name: _________________________________________________________________ Breed of Equine: _________________________ Speed or Pleasure: _____________________
Events Participated In: ____________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Awards Won: ___________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Future Endeavors: _______________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
I have read, understand, and will abide by the 2007 Youth Horse Racing Rules and Regulations.
X____________________________
Signature of Participant
___________________________
Print Participants Name
_____ / ____ / ____
Month Day Year
Liability Release and Equine Liability Act: The information provided on both pages of this form is true and is not intended to mislead. In the event that the information is discovered to be false or intentionally misleading, certification may be revoked, any purses or awards received may be revoked, and/or ineligibility for future participation in the Michigan Youth Horse Racing Program may be issued. Except in the event of gross negligence on the part of the Michigan Youth Horse Racing Program or the administrators associated with the Michigan Youth Horse Racing Program, I shall bring no claims, demands, actions and causes of action, and/or litigation, against the Michigan Youth Horse Racing Program, Michigan Department of Agriculture, Mt Pleasant Meadows, Great Lakes Quarter Horse Association, participating county fairs, and the administrators for any economic or non economic losses due to bodily injury, death, and/or property damage sustained to the participant, the participants parents/legal guardian, and/or the participants equine in relation to the Michigan Youth Horse Racing Program while participating in the events of the Michigan Youth Horse Racing Program. The waiver, release and indemnification agreement, specifically embraces each and every event sanctioned, authorized or promoted by said releasees during the entire season and applies to each event, or activity hereinabove mentioned, and has the same effect as if executed after each and every activity or event in which the undersigned participates so that the parties herein intended to be released and indemnified shall be fully and effectively released and indemnified as to each and every event herein above described,
The undersigned,
, am the (mother) (father) (guardian) of ___________________________________, a minor who is participating in the Michigan Youth Horse Racing Program do hereby represent that he/she (they), in fact, acting in such capacity and agrees to save and hold harmless and indemnify each and all of the parties herein referred to above as releasees from all liability, loss, cost, claim or damage whatsoever may be imposed upon said releasees because of any defect in or lack of such capacity to so act and release said releasees on behalf of both of the undersigned. I hereby consent to any medical, dental, or surgical treatment or procedure of an emergency nature that is necessary. ___________________________
Print Participants Name
X____________________________
Signature of Participant
_____ / ____ / ____
Month Day Year
X____________________________
Signature of Parent or Guardian
___________________________
Print Parent or Guardians Name
_____ / ____ / ____
Month Day Year
X____________________________
Signature of Witness
___________________________
Print Witnesses Name
_____ / ____ / ____
Month Day Year
Emergency Phone Numbers: Number: ( ____ ) ________________ ( ____ ) ________________ ( ____ ) ________________
Person to Contact: _________________________ _________________________ _________________________
Furthermore, I agree I will be financially responsible for treatment or procedure that is not covered by insurance. The Michigan Youth Horse Racing Program will have no financial responsibility for treatments or procedures. X____________________________
Signature of Guardian
___________________________
Print Guardians Name
_____ / ____ / ____
Month Day Year
X____________________________
Signature of Witness
___________________________
Print Witnesses Name
_____ / ____ / ____
Month Day Year