Information and Liability Waiver

For Haley Hills Farm & Inn LLC and

The Equine STAR Foundation

Rider’s Name ____________________________________________DOB_______________

Address: ____________________________________________________________________

_____________________________________________________________________________

Phone Number: ______________________ Cell Number: _________________________

Email address: ______________________________________________________________

Emergency Contact Name and Number: ______________________________________

Experience and location of previous training: _____________________________________________________________________

Health Information: 

Are all vaccines UTD?                     Yes  No 

Is Tetnus UTD?                               Yes  No 

Allergies?  (please specify)              Yes  No 

Medications?  (specify)                    Yes  No 

Special Needs?  (specify)                 Yes  No 

Concerns? ______________________________________________________________

I acknowledge the risks involved in riding and working around horses, which includes bodily injury from using, training, or being in close proximity to horses.  In addition, it is my clear understanding that both horse and rider can be injured in normal daily activities as well as during showing and competitions.  I hereby agree to hold harmless and indemnify Haley Hills Farm & Inn LLC, The Equine STAR Foundation, & Horsen’ Around Properties LLC and it’s owners and further release them from any liability or responsibility for accident, damage, injury, or illness to the undersigned or any horse owned by the undersigned or to any family member or spectator accompanying the undersigned on the premises of Haley Hills Farm & Inn LLC, White Lake, MI

Date: ____________________________  Signature ________________________________

Signature of Parent or Guardian (if above is a minor): _________________________

PHOTO PUBLICATION RELEASE (Please print name)

I, ______________________hereby grant Haley Hills Farm & Equine STAR permission to use photographs or videotape of myself, my (child and) family taken during events for use in publications as well as in online web site pages. NOTICE: If photos are published online, the photo captions will contain FIRST NAMES ONLY.

Signature ____________________________________________________ Date: __________