Riding Lesson Registration Form

Riding Lesson Registration Form
Student Name *

First Name Last Name
Birth Date *

Month Day Year Date Picker Icon
Weight *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number *

Area Code Phone Number
Cell/Work Phone Number

Area Code Phone Number
E-mail Address *
example@example.com
Parent Name (if the student is under the age of 18)

First Name Last Name
Phone Number

Area Code Phone Number
Please provide any additional information which may be helpful to the staff (Physical and/or Mental disabilities, Allergies, Medication, etc.)
Preferred riding style: *

English Western Undecided
Have you ridden before? If so, where did you previously ride? (This excludes new riders/riders that have done a public trail ride/pony ride)
If you have previously ridden, what riding level do you consider yourself under?

Level one: under 6 months of riding or just learning basics - walk, trot, canter, flatwork Level two: 6 month to 1 year; knows walk/trot/canter, jumping small cross rails and working on proper bending Level 3: strong walk/trot/canter knowledge, working on bending and lateral work; jumper over 18" Level 4: Strong walk/trot/canter knowledge, advanced bending and lateral work; jumping up to 2.6 ft or over .70 m Level 5: Strong knowledge in flatwork and over fence exceeding heights of 2.6 ft or .70 m None of the above
If you selected non of the above on the previous question, but do have riding experience, please describe below.
Health Card # *
Emergency Contact (name, relationship to rider, phone number) *
WAIVER: PLEASE READ CAREFULLY - GENERAL RELEASE

I/We hereby agree to assume all responsibility and risk from the use and rental of riding horsesfrom Our Fathers Farm/Canteen Destiny.; and further agree to hold Our Father's Farm/Canteen Destiny., Teachers,Counselors, Assistant Counselors, Trainers, Employees and Volunteers free from all damages ofliability for any injury to person or property arising as a result of use, rental or lesson, of said horsesor equipment or while staying at Our Father's Farm/Canteen Destiny.I/We further acknowledge that any physical and/or mental disabilities, as set out above, constitute full and absolutedisclosure and that accepting such full and complete disclosure there are no other medical reasons that would effect myparticipation in equestrian activities.The participant is responsible for his/her own medical coverage. I hereby give permission to have staffarrange for any emergency medical care including hospitalization if necessary.I/We grant permission to Our Father's Farm/Canteen Destiny. and anyone authorized by Our Father's Farm/Canteen Destiny to take photographsand/or videos of the above named person for instruction or publicity purposes. I agree toaccept the possibility of flaws, distortions, or inaccuracies of reproduction for whatever reason.
I/We have read Our Father's Farm/Canteen Destiny's policies . I/We understand and agree to these policies. *

I agree
Signature *

Clear
I would like to receive updates and special offers via email from Canteen Destiny

Yes No
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