🐎 Horse Riding INDEMNITY FORMS

Medical Indemnity Form

This form is intended to assist staff of Giddy Up GG’s in supporting and caring for students

in the case of any medical emergency during the course of the program.

All information will be kept in confidence.

This form needs to be filled out prior to riding

Personal Details

 

Students Name___________________________________ DOB____________________

Parent/Guardian /Next of Kin

__________________________________________________________

Address____________________________________________________

Postcode___________________________________________________

Telephone AH______________________________________________

BH________________________________________________________

Alternative emergency contact:Name______________________

ph____________________________________________________________________

Name and Address of family doctor

_____________________________________________________________________________

_____________________________________________________________________________

___________________________________________Telephone________________________

Medicare No._______________________________ Do you have ambulance cover? Y / N

Private Health Insurance Fund________________________________________________

Member No._______________________________________________________________

Medical Conditions

Please outline any medical condition which your son/daughter has currently, or has suffered with in the past

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Allergies to medication______________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Tetanus Immunisation Y/N – date of last Immunisation____________________________

Medication (both prescription and non-prescription)

Will your son/daughter to be taking medication during the course of the program? Y / N

If YES, please indicate the following:

 Name of medication ________________________________________________________

Dose and frequency ________________________________________________________

Reason for medication ______________________________________________________

_________________________________________________________________________

If student is on any medication other than prescribed medication, this has to be accompanied by a doctor’s certificate, stating dosage and frequency.

It is generally recommended that all medication be handed to staff.

You are reminded that we are not able to issue basic pain medication such as paracetamol (e.g. Panadol).

Any late changes to the above information should be conveyed (preferably in writing) to staff.

Consent to Medical Attention

Where the staff are unable to communicate with me, or it is otherwise impractical to do so, I authorise the staff in charge to:

a)     Consent to my son/daughter/self  receiving such medical or surgical attention as may be necessary by a medical practitioner, or

b)     Administer such First Aid as the staff in charge may judge reasonable.

c)      Call an ambulance where staff think it is appropriate.

Signature of Parent/Guardian/Self ________________________________________________

Date _____________________________________________________________________

 ———————————————————————————————————————————

WAIVER or AGREEMENT 

BETWEEN: Lena Driver of Giddy Up GG’s and anyone working for or on behalf of Giddy Up GG’s (Herein after called the Instructor) on one part and

 (Name of Student) ………………………………………………………………………………………………………..

Address ………………………………………………………………………………………………………………….

Phone ……………………………………………… Mobile ……………………………………………………………

Email …………………………………………………………………………………………………………………….

(herein after called the student) of the other part

 

A          The STUDENT wishes to obtain Horsemanship Instruction from the INSTRUCTOR.

 

B          The INSTRUCTOR has agreed to provide all reasonable care and responsibility with regards to such instruction, subject to the following terms and conditions, namely;

 

RIDERS WARRANTIES

 

1 It is the STUDENTS responsibility to wear an Australian Standard Approved horse-riding helmet at all times whilst riding.

2 The STUDENT is physically fit and able to ride.

3 The STUDENT is responsible for informing the INSTRUCTOR of the STUDENTS competence and experience with each task or exercise, or lack therof.

4 It is the STUDENTS responsibility to decide whether or not to participate in each task or exercise.

5 If the STUDENT provides their own horse, it is the STUDENTS responsibility to advise both the INSTRUCTOR of their horses’ behavioral problems and to ensure that their horse does not endanger the INSTRUCTOR, other STUDENTS or property.

6 The STUDENT acknowledges that horse-riding and handling is a hazardous and unpredictable activity which can cause severe injury and even death, but agrees to accept all such risks of personal injury, death or property damage to himself or caused by others.

7 The STUDENT agrees to release and discharge the INSTRUCTOR in respect of any liability whatsoever to the STUDENT for loss or damage whether for personal injury, death or property damage which the STUDENT may suffer, unless the INSTRUCTOR’s actions can be proven to be negligent in this particular incident.

8 The STUDENT indemnifies the INSTRUCTOR against any loss, damage or cost that may be incurred by the INSTRUCTOR as a result of any act or omission of the STUDENT, unless the INSTRUCTOR’s actions can be proven to be negligent in this particular incident.

9 It is the responsibility of the STUDENT  to inform the INSTRUCTOR of any conditions which may affect their own or others safety.

10 This agreement, release and indemnity shall be binding upon the STUDENT, his legal representative, heirs and next of kin.

RIDERS NAME ……………………………………………………………………………………………………………

RIDERS SIGNATURE(or PARENT/ GUARDIAN IF UNDER 18 YEARS OLD)

 ……………………………………………………………………………………………………

 

MEDIA RELEASE FORM

I, ___________________________________________________________________

parent/guardian of ___________________________________________or self,  DOB ____________  

DO  /  DO NOT  (please circle) give my consent to Giddy Up GG’s and Lena Driver to use any past or future photography, video footage or voice recording of the above said individual/s for the use of advertising, including on the internet and web site. I understand that this material will be used for public viewing.

NAME  _________________________________________________________________

SIGNATURE  _____________________________________________________________

DATE    ___ /      /___

—————————————————————————————————————————————–