Client Medical Information

Client Email

Riders Name

I agree to the following: I will only ride the horse in a safe and controlled manner I will wear an Australian Standard Approved helmet and the correct footwear at all times I will read and follow all signs on the property and follow all instructions The Instructor/Guide may cancel my ride without refunding any fee if I do not comply with any of these terms and conditions.

Yes

The number of times the rider has ridden in the last 12 months

Indicate below the number of times the rider has ridden in total

0 - 10 Limited Experience

10 - 20 Some Experience

20 - 50 Average Experience

50 - 100 Experienced

100+ Very Experienced

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Name

Emergency Contact Phone

Are there any learning difficulties that need to be discussed, so the Instructors/Guides are able to accommodate accordingly? Please describe.

Allergies: Please describe alergy and reaction

Any pre-existing medical or other condition that may affect or risk other persons or myself.

Other?

It is particularly important that people dealing with horses are immunised against tetanus. Tetanus is normally given at five years of age as Triple antigen or CDT and at fifteen years of age as ADT. Year of last tetanus immunisation

Is it necessary for you or your child to carry their own medication at all times?

Name of Medication/Drug, Time Given, Frequency and Dosage

Consent To Medical Attention I authorise the instructor in charge to administer first aid and call an ambulance. I agree to bear any cost thereby incurred.

Yes

Privacy Statement – Privacy Act 1998 By completing this form you are supplying the Provider with personal information about yourself. This information is needed to ensure your safety during your time with us. The Provider is required to collect this information by our insurance company and by the department of Workplace Health and Safety. This information you provide will not be supplied to any other organisation or used for any other purpose than that which is stated above.

Full Name of Rider

Date of Birth

Contact Number

Signature