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MENTONE PONY CLUB INC.

Registered Association No: A0021759F

Cnr Thompsons and Learmonth Roads

Patterson Lakes, VIC 3195

 

This waiver must be signed BEFORE booking a schooling or clinic session at Mentone Pony Club cross country grounds.

ASSUMPTION OF RISK FORM for riders accessing Mentone Pony Club cross country grounds, Cnr Thompsons and Learmonth Roads, Patterson Lakes VIC 3195

I UNDERSTAND AND ACKNOWLEDGE THAT:

1. I acknowledge that horse riding is an inherently dangerous activity. I recognise that there are risks specifically associated with this activity, some of which include, but are not limited to: the unpredictability of animals especially if they are frightened or hurt no matter how well trained they are; sudden changes in weather; physical exertion for which I may not be preapred for.

2. I voluntarily participate at my own risk and assume sole responsibility for any injury, death or property damage I may suffer or cause arising from participation in horse sport activities.

3. I agree to be familiar with and comply with all the rules or directions given by the proprietor in connection with riding and tending my horse at Mentone Pony Club cross country grounds.

4. Riding gear can break and fail

5. The ground can be rough and uneven especially after wet weather or extensive use.

6. My horse/pony could throw me or could brush me up against objects, fences or trees.

7. There are unfenced dams, fallen trees and other debris on the property.

8. There are many other general dangers not limited to those listed here.

9. I will jump the jumps in the direction they are intended and will stay within the limits of myself and my horse.

10. Riding of horses/ponies bareback, rugged and/or unbridled is prohibited.

11. I will always wear a safety helmet, XC riding vest, suitable clothing and riding boots.

12. I will not consume illicit drugs and/or alcohol before or during my session at MPC xc grounds.

13. I will not share the entry code comination details with anyone else.

14. I will not use the entry code to enter the grounds unless I have booked, paid and signed this waiver for the time that I am riding.

15. I will not let any other rider into the facility whom has not booked, paid and signed this waiver.

16. I will not allow another person, including but not limited to, my helper or instructor, ride my horse/pony while at the Mentone PC grounds, unless they have booked and paid for the same riding time as me and signed a waiver.

17. I will contact a Mentone PC booking officer should an accident, fall or damage occur.

18. I must hold a current PCAV, EA or HRCAV membership to ride at the grounds.

19. I will check the condition of the jumps, including take-off and landing, before jumping.

20. I accept the risks associated with the activity including the possibility of injury, death, loss or damage.

21. I agree to indemnify the proprietor against all claims made by another person against the proprietor.

 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information
I am a full riding member of the EA/HRCAV/PCAV and therefore covered for general riding activities by the EA/HRCAV/PCAVs insurance policy for personal injury and accidents*
No
Yes

My membership organisation and membership number *
I am a member of the ambulance service and am covered for ambulance transport.*
No
Yes

What date are you accessing the Mentone Pony Club cross country grounds? *

I agree to wear an Australian Standard Approved riding helmet and appropriate riding attire at all times when mounted.

I agree not to ride under the influence of alcohol or mind altering substances.

I am familiar with the rules of Mentone Pony Club and agree to comply with them.

I agree to follow all COVID-19 safety precautions.


Car registration number *

Helper/coach/instructor name and contact number
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
I am a full riding member of the EA/HRCAV/PCAV and therefore covered for general riding activities by the EA/HRCAV/PCAVs insurance policy for personal injury and accidents*
No
Yes

My membership organisation and membership number *
I am a member of the ambulance service and am covered for ambulance transport.*
No
Yes

What date are you accessing the Mentone Pony Club cross country grounds? *

I agree to wear an Australian Standard Approved riding helmet and appropriate riding attire at all times when mounted.

I agree not to ride under the influence of alcohol or mind altering substances.

I am familiar with the rules of Mentone Pony Club and agree to comply with them.

I agree to follow all COVID-19 safety precautions.


Car registration number *

Helper/coach/instructor name and contact number
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
I am a full riding member of the EA/HRCAV/PCAV and therefore covered for general riding activities by the EA/HRCAV/PCAVs insurance policy for personal injury and accidents*
No
Yes

My membership organisation and membership number *
I am a member of the ambulance service and am covered for ambulance transport.*
No
Yes

What date are you accessing the Mentone Pony Club cross country grounds? *

I agree to wear an Australian Standard Approved riding helmet and appropriate riding attire at all times when mounted.

I agree not to ride under the influence of alcohol or mind altering substances.

I am familiar with the rules of Mentone Pony Club and agree to comply with them.

I agree to follow all COVID-19 safety precautions.


Car registration number *

Helper/coach/instructor name and contact number
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
I am a full riding member of the EA/HRCAV/PCAV and therefore covered for general riding activities by the EA/HRCAV/PCAVs insurance policy for personal injury and accidents*
No
Yes

My membership organisation and membership number *
I am a member of the ambulance service and am covered for ambulance transport.*
No
Yes

What date are you accessing the Mentone Pony Club cross country grounds? *

I agree to wear an Australian Standard Approved riding helmet and appropriate riding attire at all times when mounted.

I agree not to ride under the influence of alcohol or mind altering substances.

I am familiar with the rules of Mentone Pony Club and agree to comply with them.

I agree to follow all COVID-19 safety precautions.


Car registration number *

Helper/coach/instructor name and contact number
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
I am a full riding member of the EA/HRCAV/PCAV and therefore covered for general riding activities by the EA/HRCAV/PCAVs insurance policy for personal injury and accidents*
No
Yes

My membership organisation and membership number *
I am a member of the ambulance service and am covered for ambulance transport.*
No
Yes

What date are you accessing the Mentone Pony Club cross country grounds? *

I agree to wear an Australian Standard Approved riding helmet and appropriate riding attire at all times when mounted.

I agree not to ride under the influence of alcohol or mind altering substances.

I am familiar with the rules of Mentone Pony Club and agree to comply with them.

I agree to follow all COVID-19 safety precautions.


Car registration number *

Helper/coach/instructor name and contact number
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
I am a full riding member of the EA/HRCAV/PCAV and therefore covered for general riding activities by the EA/HRCAV/PCAVs insurance policy for personal injury and accidents*
No
Yes

My membership organisation and membership number *
I am a member of the ambulance service and am covered for ambulance transport.*
No
Yes

What date are you accessing the Mentone Pony Club cross country grounds? *

I agree to wear an Australian Standard Approved riding helmet and appropriate riding attire at all times when mounted.

I agree not to ride under the influence of alcohol or mind altering substances.

I am familiar with the rules of Mentone Pony Club and agree to comply with them.

I agree to follow all COVID-19 safety precautions.


Car registration number *

Helper/coach/instructor name and contact number
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
I am a full riding member of the EA/HRCAV/PCAV and therefore covered for general riding activities by the EA/HRCAV/PCAVs insurance policy for personal injury and accidents*
No
Yes

My membership organisation and membership number *
I am a member of the ambulance service and am covered for ambulance transport.*
No
Yes

What date are you accessing the Mentone Pony Club cross country grounds? *

I agree to wear an Australian Standard Approved riding helmet and appropriate riding attire at all times when mounted.

I agree not to ride under the influence of alcohol or mind altering substances.

I am familiar with the rules of Mentone Pony Club and agree to comply with them.

I agree to follow all COVID-19 safety precautions.


Car registration number *

Helper/coach/instructor name and contact number
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
I am a full riding member of the EA/HRCAV/PCAV and therefore covered for general riding activities by the EA/HRCAV/PCAVs insurance policy for personal injury and accidents*
No
Yes

My membership organisation and membership number *
I am a member of the ambulance service and am covered for ambulance transport.*
No
Yes

What date are you accessing the Mentone Pony Club cross country grounds? *

I agree to wear an Australian Standard Approved riding helmet and appropriate riding attire at all times when mounted.

I agree not to ride under the influence of alcohol or mind altering substances.

I am familiar with the rules of Mentone Pony Club and agree to comply with them.

I agree to follow all COVID-19 safety precautions.


Car registration number *

Helper/coach/instructor name and contact number
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
I am a full riding member of the EA/HRCAV/PCAV and therefore covered for general riding activities by the EA/HRCAV/PCAVs insurance policy for personal injury and accidents*
No
Yes

My membership organisation and membership number *
I am a member of the ambulance service and am covered for ambulance transport.*
No
Yes

What date are you accessing the Mentone Pony Club cross country grounds? *

I agree to wear an Australian Standard Approved riding helmet and appropriate riding attire at all times when mounted.

I agree not to ride under the influence of alcohol or mind altering substances.

I am familiar with the rules of Mentone Pony Club and agree to comply with them.

I agree to follow all COVID-19 safety precautions.


Car registration number *

Helper/coach/instructor name and contact number
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
I am a full riding member of the EA/HRCAV/PCAV and therefore covered for general riding activities by the EA/HRCAV/PCAVs insurance policy for personal injury and accidents*
No
Yes

My membership organisation and membership number *
I am a member of the ambulance service and am covered for ambulance transport.*
No
Yes

What date are you accessing the Mentone Pony Club cross country grounds? *

I agree to wear an Australian Standard Approved riding helmet and appropriate riding attire at all times when mounted.

I agree not to ride under the influence of alcohol or mind altering substances.

I am familiar with the rules of Mentone Pony Club and agree to comply with them.

I agree to follow all COVID-19 safety precautions.


Car registration number *

Helper/coach/instructor name and contact number
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
I am a full riding member of the EA/HRCAV/PCAV and therefore covered for general riding activities by the EA/HRCAV/PCAVs insurance policy for personal injury and accidents*
No
Yes

My membership organisation and membership number *
I am a member of the ambulance service and am covered for ambulance transport.*
No
Yes

What date are you accessing the Mentone Pony Club cross country grounds? *

I agree to wear an Australian Standard Approved riding helmet and appropriate riding attire at all times when mounted.

I agree not to ride under the influence of alcohol or mind altering substances.

I am familiar with the rules of Mentone Pony Club and agree to comply with them.

I agree to follow all COVID-19 safety precautions.


Car registration number *

Helper/coach/instructor name and contact number
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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