Head Coach Release Form

Riders Interscholastic Federation of North America

Today's Date:

Contact us at 770-781-3833

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Head Coach Form Page 2

Coach’s Name: ______________________________________________

Farm:

# of years Training:

# of years riding:

Disciplines taught:

Dressage Western

Hunter Equitation

Certification :

Expiration Date:

Current Employer:

Previous Employers:

Do you have professional liability insurance?

Yes No

Policy carrier/number:

Limits:

Do you have any prior claims? No Yes*

*If yes, please indicate outcome:

Do you have, or have you had, any civil or criminal complains filed against you? No Yes*

*If yes, please indicate outcome:

Are you CPR certified?**

Yes No Scheduled for training on _______________

**Must submit proof to RIFNA.

Please indicate three (3) professional references that we may contact:

By signing this document, I verify that I:

· Have previous equestrian coaching/riding experience

· Am at least 21 years of age

· Am a high school (or GED) graduate

· Am CPR certified (current)

· Have an individual professional liability insurance policy with minimum liability coverage of $1,000,000 per accident

To the best of my knowledge, the above information is true. I also authorize RIFNA to verify the above information.

__________________________________________________________________

Signature Date: MM/DD/YY

___________________________________

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