Rider Information & Medical Form

Rider Information & Medical Form

JR Cutting & Performance Horses,

682 Old Mt Beppo Road,

Mount Beppo QLD 4313.

Phone: 0432 411 257

Email: info@jrcuttinghorses.com.au

Rider last name

Address

Birthday

Month

Day

Year

Email

Phone

Is the rider over 18 years of age

Yes

No

I agree to the following:

I will ride my horse in a safe manner.

I will WILL/WILL NOT an Australian Standard Approved Helmet

I will wear the correct footwear at all times.

I will follow all signs on the property & obey all instructions given.

I understand that the instructor/coach/guide may cancel my ride/lesson/clinic without refunding any fee if I do not comply with any of these terms & conditions.

Are there any learning difficulties that need to be discussed, so the instructors/coaches/guides are able to accomodate accordingly?

Do you (or your child) suffer from any of the following?

Yes

No

Other Pre-Existing Medical Conditions. Please tell us if there is anything we need to be aware of that is not listed above.

Do you have any allergies or reactions?

Yes

No

If yes, please give details below.

When was your last Tetanus Needle?

Within the last 5 yrs

Longer then 5 yrs ago

Unknown

Medications. Is it necessary for you (or your child) to carry their own medications at all times.

Yes

No

If yes, please supply details. Including name of drug, frequency and dose.

Consent to Medical Attention: I authorise the instructor/coach/guide to administer first aid & call an ambulance. I agree to bear the cost thereby incurred.

Date

Month

Day

Year

Signature

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