Paul Belasik Clinic (June 20-21, 2015)
Please Email to info@rustedmarefarm.com
Name:
________________________________________________________
Address:
________________________________________________________
Phone:
________________________________________________________
Email:
________________________________________________________
Emergency Contact (Riders Only):
__________________________________________________________________
Emergency Contact Phone:
__________________________________________________________________
Breed, Age of Horse, and Level of Riding:
__________________________________________________________________
Groom Name:
__________________________________________________________________
(Audit Fee Waived and Lunch Provided)
Rider ($550):
☐
Stall Fee ($50):
☐
Video ($50):
☐
Audit:
June 20, 2015 ($25)
☐
June 21, 2015 ($25)
☐
June 21-22, 2015 ($50) ☐
Payments can be made in cash, check, or credit
WAIVER OF LIABILITY & LEGAL RELEASE
FOR
RUSTED MARE FARM (BAKER O’BRIEN AND CHERI BUDZYNSKI)
23211 KELLOGG ROAD
STATE OF OHIO
(Please Print Clearly)
GRAND RAPIDS, OH 43522 (419) 832 2105
COUNTY OF WOOD
Date _____/_____/ 2015
I, ________________________________, acknowledge and accept that horseback riding and activities related thereto, involve the risk of personal
injury. By my signature (and, in case of a minor, the parent’s or guardian’s signature), the undersigned participant:
To the full extent permitted by law, including, but not limited to section 2305.321 of the Ohio Revised Code hereby waive all rights, if any, claims,
causes of action and lawsuits against Baker O’Brien and Cheri Budzynski, their family, heirs, executors, legal representatives, administrators,
successors, assigns, guests, employees, or agents affiliated with any of them in any manner (collectively, herein “O’Brien and Budzynski”), for any
injury, liability or damages which may occur while riding any horse, whether leased or owned by me or by any other person, or for any injury or
damages which may occur while participating in any activity related to horseback riding.
Agree to indemnify, defend and hold harmless from all claims, demands, and causes of action of any kind O’Brien and Budzynski or any person or
entity whose land a horseback ride crosses, for any accident, injury, or loss that might occur, and free such persons from all liability for such injury
or loss. I understand that horseback riding always involves danger and I ride at my own risk.
Agree to indemnify and hold harmless O’Brien and Budzynski from all loss, costs, expenses, damages and claims for damages, including defense
costs and attorney’s fees, for injury to or damage to the property of, any person caused or claimed to have been caused by the undersigned
participant.
Agree to take full responsibility for the undersigned and the animal the undersigned is riding. I am aware that wearing a certified safety helmet is a
good preventive measure against head injury, and further understand that helmets are required for all riders.
Understand that horseback riding involves certain dangerous risks; and further understand that horses, despite training and past characteristics, may
be unpredictable at times and can cause personal injury, death, and property damage by many means including, but not limited to, throwing the
rider, breaking into a run, falling on a rider, kicking a rider, and colliding with a rider and there can be equipment problems which contribute to
injury or loss. Therefore, the undersigned agrees that he or she (or his or her guardian if the rider is a minor) voluntarily assumes the risk of
accident or damage to the undersigned participant or his or her property.
The undersigned have carefully read the foregoing and have voluntarily signed this agreement for the purpose of granting waivers, releases,
indemnities, and assuming the risks, all as provided above.
Medical Release Horse/Rider
I further agree to allow and be financially responsible for any necessary emergency medical treatment by any available physician at any available
medical institution in the event of my injury or illness. I have read and understand this liability release. Date ____ /_____ / 2013
Print Name
Rider Signature
_______________________________________
_______________________________________
_________________________________________
(Signature of Guardian if Rider is a Minor)
____________________________________________________________________________________________________
Street Address
________________________________________________________ __________________________________________
City
St.
Zip
Home Phone
Office Phone or cell
E Mail: ___________________________________________
In Case of Emergency Notify:___________________________________________ P