Loading...

Polk County Conservation Board Jester Park Equestrian

Center Equine Release and Hold Harmless Agreement 

WARNING

UNDER IOWA LAW, A DOMESTICATED ANIMAL PROFESSIONAL IS NOT LIABLE FOR DAMAGES SUFFERED BY, AN INJURY TO, OR THE DEATH OF A PARTICIPANT RESULTING FROM THE INHERENT RISKS OF DOMESTIC ANIMAL ACTIVITIES, PURSUANT TO IOWA CODE CHAPTER 673. YOU ARE ASSUMING INHERENT RISKS OF PARTICIPATING IN THIS DOMESTIC ANIMAL ACTIVITY.

I understand that activities involving horses carry inherent risks and can be potentially dangerous despite all safety precautions. A horse may behave in a manner that result in damages to property or an injury or death to a person. Risks associated with the activity may include but are not limited to injuries caused by bucking, biting, stumbling, rearing, trampling, scratching, falling, or butting.

The horse may react unpredictably to conditions, including, but not limited to, a sudden movement, loud noise, an unfamiliar environment, or the introduction of unfamiliar persons, animals, or objects. The horse also may react in a dangerous manner when a condition or treatment is considered hazardous to the welfare of the animal; a collision occurs with an object or animal; or a participant fails to exercise reasonable care, take adequate precautions, or use adequate control when engaging in a domesticated animal activity, including failing to maintain reasonable control of the horse or failing to act in a manner consistent with the person’s abilities.

I represent that I am in good physical condition, and I am not aware of any diseases or injury that would be aggravated or result in my being incapacitated or injury that would aggravated or result in my being incapacitated or injured during any program participation except as designated herein.

There also are risks that I, my child or my ward may take while mounting, leading, riding, feeding or otherwise interacting with horses. I also understand that I, my child or my ward can help to minimize the risks by carefully following the direction of the staff and wearing a ASTM/SEI certified safety helmet.

I hereby grant permission and authority to Jester Park Equestrian Center (JPEC) and those acting on its behalf to obtain and prompt medical attention in the event I, or my child or my ward may become injured. Should medical treatment be required during or following my, my child’s or ward’s participation in an activity associated with (JPEC), I agree that I and/or my, my child’s or ward’s insurance company shall pay for any and all expenses related thereto.

In consideration of (JPEC) allowing the participant to participate in this activity, I, on behalf of the participant, myself, and the participant’s and/or my heirs, personal representatives, and assigns, hereby agree to hold harmless, release and discharge (JPEC), its employees, directors, and anyone associated, either directly or indirectly, with JPEC from any and all claims, demands, causes of action, and liability, whether the same be known or unknown, anticipated or unanticipated, due to JPEC and its representatives’ ordinary negligence. I further agree, except in the event of JPEC’s gross negligence or willful misconduct, that I will not bring any claim or legal action against JPEC, its employees, directors or anyone associated with JPEC.

The terms of this agreement shall be construed as the entire agreement and may not be altered, amended or modified except in writing and signed by both parties. This agreement shall be governed by the laws of the state of Iowa and shall remain in effect for ach activity with JPEC whether on or off the premises of 11171 NW 103rd Court, Granger, Iowa.

By signing this document, I acknowledge that I have received the equine release and hold harmless agreement and I have been provided an opportunity to review it, and I understand its terms and freely and voluntarily sign the same.

PARENT’S OR LEGAL GUARDIAN’S ADDITIONAL INDEMNIFICATION

Must be completed for all participants under the age of 18 (“minors”). In consideration of the below named Minor(s) being permitted by JPEC to participate in its activities and to use the facilities, I further agree to indemnify and hold harmless PCCB from any and all claims which are brought by, or on behalf of any Minor listed below, and which are in any way connected with such use or participations by such Minor. I further certify that I am the parent or legal guardian of all Minors listed in this Agreement. 


First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
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*
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Photo/Video Release
Check box if you grant JPEC the right to photograph, videotape, and/or record me and/or my child/ward to use my or my child's/ward's name, face, likeness, voice and appearance in connection with exhibitions, publicity, advertising, and promotional materials without reservation or limitations.*
Yes
No


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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!