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Release, Assumption of Risk, and Indemnity Agreement
Member Information:
Rider Name: ____________________________________________________________
Rider Street Address: _____________________________________________________
Rider City/State/Zip: ______________________________________________________
Rider County: _______________________ Rider Home #: (_____) _____________
Date of Birth: _____________________ Current age: __________
EFFECTIVE DATE of this Release, Assumption of Rish and Indemnity Agreement: _________
Assumption of Risk and Waiver
I/We understand that there are inherent risks of serious injury or even death possible with equine activities, and I/We assume the risk for participation in equine activities. On behalf of myself, my heirs and assigns, executors and administrators, I/We hereby waive and release forever any and all liability and all claims for damages against Riders Interscholastic Federation of North America, Inc. (RIFNA), its Board of Governors, Instructors, Administrators, Volunteers and/or Employees for any and all injuries and/or losses I/my son/my daughter/my ward may sustain associated with my child’s voluntary participation in RIFNA activities.
Rider's Signature: ____________________________________________Date_________
(If under 18 years of age, parent/legal guardian signature required below)
Parent/Legal Guardian Signature: ________________________________________ Date: _______________
Indicate relationship to Rider: __ Mother __ Father __ Legal Guardian
_______________________________________ ____________________________________________________________
RIFNA Medical Information and Treatment Release
In consideration of my/my child’s participation in any RIFNA activity and the inherent risks of equine activity that may result in injury/harm requiring emergency medical treatment, I authorize RIFNA (to include its successors or assigns, officials, officers, directors, employees, agents and/or volunteers) to obtain and release to any RIFNA activity personnel (including, but not limited to, organizers, instructors, test examiners, chaperons) AND to any first aid and safety personnel, medical professionals, and treating medical facility, any information regarding my/my child’s medical history, symptoms, treatment, exam results and/or diagnosis. I/We have fully disclosed in the Section V: Medical / Insurance / Emergency Contact Information any pre-existing conditions, allergies, and/or allergic reactions to medication that I/my child has.
Further, by my/our signature below, I/we authorize any medical provider to transport and commence first aid or emergency treatment, for which I/We agree to be liable, until such time that I/we can be contacted to give further Consent to Treatment.
Further, by my/our signature below, I/we hereby authorize any medical professional to accept this form as my/our consent to treat, my/our consent to accept financial responsibility for any and all expenses related thereto, and our agreement to hold RIFNA or its agents harmless.
I HAVE READ THIS ENTIRE RELEASE AND ACKNOWLEDGE MY AGREEMENT BY:
Rider's Signature: ____________________________________________Date_________
(If under 18 years of age, parent/legal guardian signature required below)
Parent/Legal Guardian Signature: ________________________________________ Date: _______________
Indicate relationship to Rider: __ Mother __ Father __ Legal Guardian
_____________________________________________________________________________________________________
Release to Use Photographs, Video, Name and Other Reproductions
I hereby grant to Riders Interscholastic Federation of North America, Inc. (RIFNA), and its employees, legal representatives and assigns in the performance of their duties for RIFNA , the absolute right and permission to use or copyright, in its own name or otherwise, and re-use, publish and re-publish photographic pictures, video, electronic images or other reproductions of me, or my child or in which I or my child may be included, in whole or in part, without restriction as to changes or alterations, in conjunction with or without my own name, in color or otherwise, made through any medium, and in any and all media now or hereafter known for illustration, promotion, art, advertising, and trade, including film, photographic, video, electronic or digital formats or reproductions, or any other purpose whatsoever. I also consent to the use of any printed or electronic matter in conjunction therewith. The uses and rights granted herein are donated to RIFNA freely and without financial consideration as a public service.
I hereby waive any right that I may have to inspect or approve the finished product or product, the advertising copy or other matter that may be used in connection therewith or the use to which it may be applied.
I hereby release, discharge and agree to hold harmless RIFNA, its employees, departments, legal representatives and assigns, and all persons acting under this Release, from any liability for such use, including by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in such use or in any subsequent processing thereof, as well as any publication thereof, including without limitation any claims for libel or invasion of privacy.
I hereby warrant that I am of legal age and have the right to contract in my own name, or I am the parent or legal guardian of the subject for whom this Release is granted. I have read the above Release, prior to its execution, and I am fully familiar with and understand the contents thereof. This Release shall be binding upon me and my heirs, legal representatives, and assigns.
Rider's Signature: ____________________________________________Date_________
(If under 18 years of age, parent/legal guardian signature required below)
Parent/Legal Guardian Signature: ________________________________________ Date: _______________
Indicate relationship to Rider: __ Mother __ Father __ Legal Guardian
_____________________________________________________________________________
This release affects your legal rights.
If not understood, please consult your own legal counsel.
I/WE HAVE READ THIS DOCUMENT; I/WE UNDERSTAND IT IS A RELEASE OF ALL CLAIMS. I/WE APPRECIATE AND ASSUME ALL RISKS INHERENT IN EQUINE ACTIVITIES.
Rider Signature (if 18 years or older): ___________________________________________________
____________________________________ ____________________________________
Signature of Mother /Female Guardian Signature of Father/Male Guardian
*All signatures must be witnessed by a notary and listed as personally appearing in the appropriate place on the form. Be sure that notary
signs, dates and places his/her seal on the form
NOTARY STATEMENT:
On this ___________day of_______________ 20___, before me personally appeared __________________________
______________________________________________ known to be the persons who executed the foregoing Release and acknowledged that they signed same as their free act and deed.
__________________________________________________.
Notary Public Signature
My Commission Expires: __________________
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Participant Membership Release Form