Loading...

MORNINGTON PENINSULA PONY CLUB INC.

Baxter Park, Sages Road, Baxter
PO Box 4
Baxter Vic 3911
Incorporation No. ARBN 0011489M

Assumption of Risk Form
- for riders accessing MPPC Grounds, Sages Rd, Baxter

  1. I acknowledge that horse riding is an inherently dangerous activity. I recognize that there are risks specifically associated with this activity, some of which include: the unpredictability of animals especially if they are frightened or hurt no matter how well trained they are: sudden and unexpected changes in weather: physical exertion for which I may not be prepared 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 MPPC Grounds.
  4. I accept the risks associated with the activity including the possibility of injury, death, loss or damage.
  5. I agree to indemnify the proprietor against all claims made by another person against the proprietor.

First Participant's Name

First Name*

Last Name*
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 EFA/HRCAV/PCAV and therefore am covered for general riding activities by the EFA/HRCAV/PCAV 's insurance policy for personal injury and accidents.


My membership organisation and membership number is *

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

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

I am familiar with the rules of MPPC and agree to comply with them. 

I am a member of the ambulance service and am covered for ambulance transport.*
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 EFA/HRCAV/PCAV and therefore am covered for general riding activities by the EFA/HRCAV/PCAV 's insurance policy for personal injury and accidents.


My membership organisation and membership number is *

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

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

I am familiar with the rules of MPPC and agree to comply with them. 

I am a member of the ambulance service and am covered for ambulance transport.*
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 EFA/HRCAV/PCAV and therefore am covered for general riding activities by the EFA/HRCAV/PCAV 's insurance policy for personal injury and accidents.


My membership organisation and membership number is *

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

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

I am familiar with the rules of MPPC and agree to comply with them. 

I am a member of the ambulance service and am covered for ambulance transport.*
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 EFA/HRCAV/PCAV and therefore am covered for general riding activities by the EFA/HRCAV/PCAV 's insurance policy for personal injury and accidents.


My membership organisation and membership number is *

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

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

I am familiar with the rules of MPPC and agree to comply with them. 

I am a member of the ambulance service and am covered for ambulance transport.*
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 EFA/HRCAV/PCAV and therefore am covered for general riding activities by the EFA/HRCAV/PCAV 's insurance policy for personal injury and accidents.


My membership organisation and membership number is *

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

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

I am familiar with the rules of MPPC and agree to comply with them. 

I am a member of the ambulance service and am covered for ambulance transport.*
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 EFA/HRCAV/PCAV and therefore am covered for general riding activities by the EFA/HRCAV/PCAV 's insurance policy for personal injury and accidents.


My membership organisation and membership number is *

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

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

I am familiar with the rules of MPPC and agree to comply with them. 

I am a member of the ambulance service and am covered for ambulance transport.*
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 EFA/HRCAV/PCAV and therefore am covered for general riding activities by the EFA/HRCAV/PCAV 's insurance policy for personal injury and accidents.


My membership organisation and membership number is *

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

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

I am familiar with the rules of MPPC and agree to comply with them. 

I am a member of the ambulance service and am covered for ambulance transport.*
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 EFA/HRCAV/PCAV and therefore am covered for general riding activities by the EFA/HRCAV/PCAV 's insurance policy for personal injury and accidents.


My membership organisation and membership number is *

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

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

I am familiar with the rules of MPPC and agree to comply with them. 

I am a member of the ambulance service and am covered for ambulance transport.*
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 EFA/HRCAV/PCAV and therefore am covered for general riding activities by the EFA/HRCAV/PCAV 's insurance policy for personal injury and accidents.


My membership organisation and membership number is *

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

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

I am familiar with the rules of MPPC and agree to comply with them. 

I am a member of the ambulance service and am covered for ambulance transport.*
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 EFA/HRCAV/PCAV and therefore am covered for general riding activities by the EFA/HRCAV/PCAV 's insurance policy for personal injury and accidents.


My membership organisation and membership number is *

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

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

I am familiar with the rules of MPPC and agree to comply with them. 

I am a member of the ambulance service and am covered for ambulance transport.*
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*
Check to receive information, news, and discounts by e-mail.
I, being the parent/guardian of the above named minor(s), confirm that I have read the whole of this document and have taken all necessary action to ensure that I am aware of the activity which the above named, will be participating in and consent to his/her participation. In doing so I acknowledge that equestrian activities are dangerous and that accidents causing death, injury and property damage can and do happen. I agree that Mornington Peninsula Pony Club, its officers or members shall not be under any liability whatsoever for the death, injury, loss or damage, which may be suffered or incurred by the above named or by me as parent/guardian being present at the activities.
Parent or Guardian's Name

First Name*

Last Name*
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 EFA/HRCAV/PCAV and therefore am covered for general riding activities by the EFA/HRCAV/PCAV 's insurance policy for personal injury and accidents.


My membership organisation and membership number is *

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

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

I am familiar with the rules of MPPC and agree to comply with them. 

I am a member of the ambulance service and am covered for ambulance transport.*
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