Corner Stone Farm

Physician Name:                             Tel#:                       

Emergency Contact Name and phone number :                                   

 (other than above)     

Have you ever made an insurance claim in your past for personal injury? y/n

Please advise of any medical conditions,

ie. arthritis asthma, diabetes,  allergies, ADD, other. Do you carry and Epi- pen. Have you or your child received any psychological/psychiatric/family therapy in the last 12 months? 

Are you or your child currently taking any medication? Please note that all medications should be forwarded to the Riding Instructor  with full doctor's instructions. Under NO circumstances should a child carry his/her medication unsupervised. 
Do you/your child suffer from back problems? Yes /No (circle one)
Do you/ your child suffer from neck pain? Yes / No (circle one )
Are you/your child pregnant ? Yes /No (circle one) If you become pregnant at a later date I agree  that I will tell my instructor.

Are you currently on disability?  

Do you have any special needs?

Please give any details of any health problems that you may affect your riding. Please include a note with medical form.

Medical/Release Form The rider/camper and/or  his/her parent(s) and/or guardian(s) hereby acknowledge the risks and hazards inherent in riding and working around animals, not to be limited to: horses, chickens,  dogs various wildlife and cats and agree to assume all responsibility and risk of bodily injury or damage to property and further agree to hold harmless and indemnify Corner Stone Farm  and its owners, employees, volunteers, agents, and representatives from all claims for any bodily injury to persons or damage to property arising out of or resulting from the riding or  use of Corner Stone Farms’ premises or use of horses at or from Corner Stone Farm , as a rider, groom or spectator or otherwise in any type of Corner Stone Farms organize, sponsored, supported or endorsed activity, whether on Corner Stone Farm  premises or elsewhere, and including transportation provided Corner Stone Farm  or the individuals or organizers referred to herein. The student and his/her parent(s) and/or guardian(s) do hereby consent to any medical examination, treatment or medical services that may be rendered to said student under the general or specific instructions of any physician or hospital. It is understood that this consent is given in advance of any specific diagnosis or treatment. The camper and the undersigned parent(s) and/or guardian(s) agree to assume responsibility for payment of all fees for doctors, hospitals, ambulances and/or other medical charges reasonably and necessarily incurred. Insurance is the responsibility of the rider/camper and/or his/her parents. The student and his/her parent(s) and/or guardian(s) do hereby consent that photos/images of the student/rider may be used in Corner Stone Farm’s   articles and advertisements without payment or remuneration to that said camper/rider.

 I agree to inform Catherine Colwell , Joseph McAllister and/or  representatives of Corner Stone Farm if any of the above details change. I agree to abide by all the rules of Corner stone Farm while I am a client of the above establishment.  
If you have any questions about filling out the forms please contact Cathy.

  Cheque made out to Cathy Colwell
Should you need to withdraw you/your child from the lesson program, arrangements can be made to credit . All deposits are non-refundable. 50% of lesson cards are considered a deposit towards registration in the program.

Signature of rider:__________________________________

Print name: ______________________________________

Date and Signature :____________________________________ 

Parent or Guardian signature if client is a minor :____________________

 Please submit this form with your Waiver.  You need you paper work to be done prior to or on your first Lesson arrival at Corner Stone Farm