HOLLOW OAK FARM SUMMER SERIES RIDER ENTRY FORM
EX NUMBER:__________ DATE:________________ NAME:_____________________________________
TELEPHONE:_______________________________
ADDRESS:_________________________________
___________________________________________ EMAIL:____________________________________
AGE AS OF 12/1/09:__________________________
DOB:______________________________________
VHSA NUMBER:______________________________
BHSA NUMBER:______________________________
AMATEUR:    Y    N                  JUNIOR:   Y     N
HORSES NAME:_______________________________
OWNER'S NAME:______________________________
OWNER'S ADDRESS:___________________________
___________________________________________
HEIGHT OF ANIMAL:___________________________
VHSA REG:___________________________________
COGGINS DATE:______________________________
REQUISITION #:_____________________________ DIVISION:___________________________________
CLASS NUMBERS:______________________________ ____________________________________________ ____________________________________________

WAIVER FOR RELEASE OF LIABILITY

ADVANCE RELEASE FOR ULTRA-HAZARDOUS ACTIVITY

___________________________________________(RIDER'S NAME) REFERRED TO AS PARTICIPANT, AND HOLLOW OAK FARM, INC., AS PROVIDER, BOTH PARTIES AGREE:

0. THIS ACTIVITY IS BY ITS NATURE HAZARDOUS AND DESPITE THE EXERCISE OF ALL DUE CARE, PERSONAL INJURIES OR DEATH MAY OCCUR WHILE RIDING HORSES. _________ (INITIAL).
0. PROVIDER ASSUMES PARTICIPANT IS FULLY INFORMED ABOUT RISKS OF ACTIVITY BY SIGNING THIS FORM AND PARTICIPATING IN EVENT._________(INITIAL).
0. PARTICIPANT, ON BEHALF OF PARTICIPANT AND HEIRS, SUCCESSORS AND ASSIGNS, HEREWITH RELEASES PROVIDER FROM ANY AND ALL LIABILITY FOR PERSONAL INJURIES, CONSORTIUM OR OTHER CLAIMS ARISING OUT OF PARTICIPATING IN THE EVENT, EXCEPT FOR ANY ACTION RESULTING FROM WILLFULL AND MALICIOUS ACTIONS BY THE PROVIDER.________(INITIAL).
0. I HAVE READ AND AGREE TO FOLLOW RULES LISTED IN HOLLOW OAK FARM INC., SUMMER SCHOOLING SERIES PRIZE LIST. I AM AWARE THAT FAILURE TO ABIDE BY RULES MAY CAUSE FOR DISQUALIFICATION FROM SHOWS.________(INITIAL).

SIGNED:____________________________________(PARENT SIGNATURE IF UNDER 18 YRS)

NAME PRINTED:____________________________________________________________________

RELATIONSHIP TO PARTICIPANT:_______________________________________________________