MTN. EMPIRE~CAMPO KIWANIS GYMKHANA
SIGN-UP FORM 3/21/15
Name (Rider)
Horse(s)
Address:
______________________________________
Phone #:
E-Mail: __________________________
Date:
Signature:
Adult:
(Parent/Guardian of minor)
DIVISIONS:
Open
__________________________
Intermediate II __________________________
Intermediate I
______________________
Novice
______________________
Beginner
______________________
Lead Line
(Free) First 2 events ONLY
EVENTS:
Single Pole:
__________
Mountain Cow Horse: _________
Speed Barrels:
__________
Texas Barrels: _______________
Jack Pot Barrels:____________($10.00 per run. Winning time earns ½ the pot)
All Participants:
$5.00 grounds fee per horse
Adults (18 and up): $15.00 participant fee
Youth (17 and under): $5.00 participant fee
Total Due:
Cash
Check #
Safety Helmet Must Be Worn For All Riders Under 18 yrs of Age
PARTICIPANT HOLD HARMLESS RELEASE
This release contains important limitations of legal liability – Please read it!
THE UNDERSIGNED STATE(S) AS FOLLOWS:
I acknowledge that sports activities, including but not limited to, motorcycle riding, bull riding and competitive and
pleasure horse riding and driving contain inherent risks of injury or death and damage to me personally, to my
horse(s), and to my equipment. Knowing these facts, I nevertheless, in consideration of your acceptance of this form,
hereby for myself, my heirs, executors and administrators waive, release and discharge and hold harmless CAMPO
EVENT AND EQUESTRIAN FACILITY (CLEEF) ,252 SHANNON ROAD, CAMPO, CA. 91906, and THE MOUNTAIN
EMPIRE/CAMPO KIWANIS and their affiliates and all other persons and organizations in any way connected with the
events, property, boarding, lessons, clinics or any other activity described herein, their representatives, heirs,
executors, administrators and assignees from any and all right, claim or liability for damages or for any and all injuries
that might be sustained by me, including injuries to animals or from any and all claims of any kind or nature that I
might have as a result of, or arising out of, my participation in any activity. Further, I do hereby acknowledge that this
release will extend to acts of anyone or any animal or any equipment within my control. I further agree that I will
defend, indemnify and hold harmless CLEEF 252 SHANNON ROAD, CAMPO, CA 91906 and THE MOUNTAIN
EMPIRE/CAMPO KIWANIS, their affiliates, officials, property owners and agents against all claims, demands, and
causes of action including court costs and attorney’s fees, directly or indirectly arising from any action or other
proceeding brought by or prosecuted for my benefit contrary to this release, extended to all claims of every kind and
nature whatsoever known or unknown and expressly waive any benefits I may have under section 1542 of the
California Civil Code relating to the release of unknown claims. This waiver applies to all events or activities taking
place and/or originating at the above listed address/property and at any other property(ies) owned by any of the
entities listed above.
I do herby acknowledge that I have read the foregoing paragraph and do know and understand the content
thereof.
PRINT NAME:
DATE:
SIGNATURE:
MINORS must have the following liability release signed by their parent(s) or legal guardian(s):
I/We, the undersigned parents/guardians of:
for and in consideration of our
child’s participation at CLEEF activities, acknowledge that I/we have read the waiver, release and hold harmless
agreement written above and we expressly agree that the terms and conditions of said waiver, release and hold
harmless agreement shall apply to and be binding upon us and our minor child insofar as it pertains to his or her
participation and to any injury or damage said minor child or his or her horse may sustain or cause as a result of said
participation. I declare under penalty of perjury that the foregoing is true and correct. Executed
this
day of
, 20( ) at (city)
, California.
MOTHER:
LEGAL GUARDIAN:
FATHER:
PHONE #:
I do hereby acknowledge that I have read the foregoing paragraphs and do know and understand the content
thereof.
SIGNATURE:
DATE: