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This form is for registering you or your child for lessons with Meadow Brook Stables. We promise to keep all the information in this form secure and confidential. 

Please complete all sections below so that I am able to provide the best possible cover in case of emergency.

First Students Name

First Name*

Middle Name

Last Name*

Phone*
First Students Date of Birth*
First Students Signature*
Second Students Name

First Name*

Middle Name

Last Name*
Second Students Date of Birth*
Second Students Signature*
Third Students Name

First Name*

Middle Name

Last Name*
Third Students Date of Birth*
Third Students Signature*
Fourth Students Name

First Name*

Middle Name

Last Name*
Fourth Students Date of Birth*
Fourth Students Signature*
Fifth Students Name

First Name*

Middle Name

Last Name*
Fifth Students Date of Birth*
Fifth Students Signature*
Sixth Students Name

First Name*

Middle Name

Last Name*
Sixth Students Date of Birth*
Sixth Students Signature*
Seventh Students Name

First Name*

Middle Name

Last Name*
Seventh Students Date of Birth*
Seventh Students Signature*
Eighth Students Name

First Name*

Middle Name

Last Name*
Eighth Students Date of Birth*
Eighth Students Signature*
Ninth Students Name

First Name*

Middle Name

Last Name*
Ninth Students Date of Birth*
Ninth Students Signature*
Tenth Students Name

First Name*

Middle Name

Last Name*
Tenth Students Date of Birth*
Tenth Students Signature*
Students 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*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Allergies

Please list any known allergies, including but not limited to: Food, Bees/Insects, Environmental, Drugs. *
Epi-Pen Required?*
No
Yes

Please detail any disability or medical conditions that may affect your ability to ride. This may include, but not be limited to any back problems and any condition which can affect balance or cause blackouts/loss of consciousness/fitting for example. If you are unsure about any existing medical conditions please consult your doctor. *

Please give brief details of any medication or assistance we may need to know about that may affect your ability to ride safely. *
Riding Experience:
Please check one of the choices below so we can find an appropriate class for you: *
Complete Beginner (never ridden or only ridden on lunge line or being lead around)
Beginner (beginning walk and jog/trot independently)
Beginner Novice (walk, jog/trot independently, lope/canter on lunge line)
Novice (walk, jog/trot, lope/canter independently)
Intermediate (lope/canter independently, has jumped up to 2ft, worked on advanced maneuvers)
Advanced (confident at all three gaits, lots of experience, has owned or does own a horse, or has taken extensive lessons in the past)
Photo Release:
I ___ DO or ___ DO NOT consent to and authorize the use and reproduction by Meadow Brook Stables any and all photographs and other audio/visual materials taken of me or my child for promotional material, social media, education activities, exhibitions or for any other use for the benefit of the program.*
DO
DO NOT
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*

Middle 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.


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