Loading...
  1. I understand that horse-back riding is a high risk sport and the inherent dangers of riding or being around horses and am participating at mine and my child’s own risk. Serious injury may result from using this facility. I am willing to accept the risk of working with, around and on horses.
  2. Fox Island Equestrian, LLC., The Blankenship Family Trust, Kirsten and Wesley Blankenship, husband and wife and/or as single people, all interested owner’s, employee’s, agents, and/or volunteers harmless for any and all injuries or illness injured by myself, my minor child and any others that accompany me on said property. I shall bring no claims, demands, actions, causes or action and/or litigation against Fox Island Equestrian, LLC., The Blankenship Family Trust, Offies Equestrian, LLC, Kirsten and Wesley Blankenship, husband and wife and/or as single people, all interested owner’s, employee’s, agents, and/or volunteer as previously stated for any loss due to bodily injury or death sustained by me, my minor children, legal ward, or horse(s) in relation to the premises and operation of this facility or of sight eventing shows., which includes riding, handling, or being near horses and or other animals.
  3. I understand and agree that Fox Island Equestrian, LLC is not responsible for any act, occurrence, or element of nature that scare, endanger, or cause harm to a horse, causing it to react to an unsafe manner.
  4. I acknowledge that I am familiar with horse riding and understand the rules governing special activities and the importance of following Fox Island Equestrian Rules.
  5. I agree that prior to any horse related activity, I will inspect horse, equipment, facilities, etc., and if I believe anything to be unsafe or beyond my capability, I will immediately notify the person in charge and refuse to participate.
  6. I acknowledge and fully understand that I will be engaged in an activity that might result in serious injury including permanent disability or death, and serve social and economic loss. Not only by my actions, inaction, or negligence; but by the action, inaction and negligence of others, the rules of the sport/activity, or conditions of premises or equipment used, Further, I acknowledge that there may be other risks, not known to me or foreseeable at this time.
  7. I am aware of the risks involved with horseback riding and I assume these risks and accept personal responsibility for the damages following such injury, permanent disability or death.
  8. Understand that no pets other that the animals of Fox Island Equestrian will be allowed on the property.
  9. I have checked with my child’s physician and my child has been given a clean bill of health to participate in horse related activities OR has specific written permission by the child’s physician and/or attending health care professional(s) to participate in horse related activities.
  10. I understand that Fox Island Equestrian cannot allow a person or persons to participate in any horse-related activity(s) if they used: alcohol, controlled substances or any mood/mind altering substances. This includes illegal drugs, as well as prescription medications, if use of said medications any way impair’s a person’s alertness or perception.
  11. I understand and agree that anyone using this facility and/or parent/guardian will repair or reimburse Fox Island Equestrian for all expenses which include materials and time in the event of any damage to equipment, jumps, arenas, or any part of the property that is damaged by their horses(s) or themselves.
  12. I am aware that inhumane treatment of the horse(s)or repeated unsafe acts will immediately void all agreements and I will forfeit any fees and rights to access this center.
  13. I understand that the stable owners shall not be liable for an injury to the horse(s) or damage to any property should the said horse(s) escape from the enclosure or while on the property. 

I hereby by agree and acknowledge I read items 1-13. 


I have read this warning and release, and understanding that I give up substantial rights by signing it, and knowing this I sign freely and voluntarily agree to participate and/or have my minor child participate, knowing these risks and conditions involved and do so of my own free will. 

Signature of Participant OR Signature of Parent/Guardian if Participant is a Minor:

Today's Date: November 21, 2024

Location Release of Liability Form

I, (Parent/Guardian), for (Student Rider), HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN ANY/ALL ACTIVITIES ASSOCIATED WITH Fox Island Equestrian, LLC, Wesley A. Blankenship and Kirsten Marie Rachon Blankenship, husband and wife; The Blankenship Living Trust (Farm Owner's), located at 977 Kamus Dr, Fox Island, WA 98333, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault.

I certify that I am physically fit, have sufficiently prepared or trained for participation in this activity, and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my participation in this activity.

I acknowledge that this Accident Waiver and Release of Liability Form will be used by the event holders, sponsors, and organizers of the activity in which I may participate, and that it will govern my actions and responsibilities at said activity.

In consideration of my application and permitting me to participate in this activity, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows:

(A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this activity, THE FOLLOWING ENTITIES OR PERSONS: Fox Island Equestrian and Offie's Equestrian and/or their directors, officers, employees, volunteers, representatives, and agents, and the activity holders, sponsors, and volunteers;

(B) INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity, whether caused by the negligence of release or otherwise.

I acknowledge that they are NOT responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf.

I acknowledge that this activity may involve a test of a person's physical and mental limits and carries with it the potential for death, serious injury, and property loss. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, lack of hydration, and actions of other people including, but not limited to, participants, volunteers, monitors, and/or producers of the activity. These risks are not only inherent to participants, but are also present for volunteers.

I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during this activity.

I understand while participating in this activity, I may be photographed. I agree to allow my photo, video, or film likeness to be used for any legitimate purpose by the activity holders, producers, sponsors, organizers, and assigns.

The Accident Waiver and Release of Liability Form shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.

I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL. 

Signature of Rider/Student OR Signature of Parent/Guardian if Rider/Student is a Minor:

Today's Date: November 21, 2024

977 Kamus Drive

Fox Island, WA 98333

651-270-6331

www.foxislandequestrian.com

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

This consent form should be taken with the participant to the hospital/urgent

Additional information will assist in treatment:


Last Tetanus:

Allergies to medications or over the counter medications:

Allergies to food:

Below area is to share any special request, current medications, blood type or pertinent information for medical staff?

Primary Physician:

Physician's Telephone:

Insurance:

Policy #:

Policy Primary Card Holder:
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

This consent form should be taken with the participant to the hospital/urgent

Additional information will assist in treatment:


Last Tetanus:

Allergies to medications or over the counter medications:

Allergies to food:

Below area is to share any special request, current medications, blood type or pertinent information for medical staff?

Primary Physician:

Physician's Telephone:

Insurance:

Policy #:

Policy Primary Card Holder:
Third Participant's Name

First Name*

Middle Name

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

This consent form should be taken with the participant to the hospital/urgent

Additional information will assist in treatment:


Last Tetanus:

Allergies to medications or over the counter medications:

Allergies to food:

Below area is to share any special request, current medications, blood type or pertinent information for medical staff?

Primary Physician:

Physician's Telephone:

Insurance:

Policy #:

Policy Primary Card Holder:
Fourth Participant's Name

First Name*

Middle Name

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

This consent form should be taken with the participant to the hospital/urgent

Additional information will assist in treatment:


Last Tetanus:

Allergies to medications or over the counter medications:

Allergies to food:

Below area is to share any special request, current medications, blood type or pertinent information for medical staff?

Primary Physician:

Physician's Telephone:

Insurance:

Policy #:

Policy Primary Card Holder:
Fifth Participant's Name

First Name*

Middle Name

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

This consent form should be taken with the participant to the hospital/urgent

Additional information will assist in treatment:


Last Tetanus:

Allergies to medications or over the counter medications:

Allergies to food:

Below area is to share any special request, current medications, blood type or pertinent information for medical staff?

Primary Physician:

Physician's Telephone:

Insurance:

Policy #:

Policy Primary Card Holder:
Sixth Participant's Name

First Name*

Middle Name

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

This consent form should be taken with the participant to the hospital/urgent

Additional information will assist in treatment:


Last Tetanus:

Allergies to medications or over the counter medications:

Allergies to food:

Below area is to share any special request, current medications, blood type or pertinent information for medical staff?

Primary Physician:

Physician's Telephone:

Insurance:

Policy #:

Policy Primary Card Holder:
Seventh Participant's Name

First Name*

Middle Name

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

This consent form should be taken with the participant to the hospital/urgent

Additional information will assist in treatment:


Last Tetanus:

Allergies to medications or over the counter medications:

Allergies to food:

Below area is to share any special request, current medications, blood type or pertinent information for medical staff?

Primary Physician:

Physician's Telephone:

Insurance:

Policy #:

Policy Primary Card Holder:
Eighth Participant's Name

First Name*

Middle Name

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

This consent form should be taken with the participant to the hospital/urgent

Additional information will assist in treatment:


Last Tetanus:

Allergies to medications or over the counter medications:

Allergies to food:

Below area is to share any special request, current medications, blood type or pertinent information for medical staff?

Primary Physician:

Physician's Telephone:

Insurance:

Policy #:

Policy Primary Card Holder:
Ninth Participant's Name

First Name*

Middle Name

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

This consent form should be taken with the participant to the hospital/urgent

Additional information will assist in treatment:


Last Tetanus:

Allergies to medications or over the counter medications:

Allergies to food:

Below area is to share any special request, current medications, blood type or pertinent information for medical staff?

Primary Physician:

Physician's Telephone:

Insurance:

Policy #:

Policy Primary Card Holder:
Tenth Participant's Name

First Name*

Middle Name

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

This consent form should be taken with the participant to the hospital/urgent

Additional information will assist in treatment:


Last Tetanus:

Allergies to medications or over the counter medications:

Allergies to food:

Below area is to share any special request, current medications, blood type or pertinent information for medical staff?

Primary Physician:

Physician's Telephone:

Insurance:

Policy #:

Policy Primary Card Holder:
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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:*
Consent to Treat Minor-Medical Release

Consent to Treat Minor-Medical Release

I, parent or guardian (full legal name provided below) of, minor (full legal name provided below), (Minor date of birth provided below), do hereby consent to any medical care and the administration of anesthesia determined by a physician to be necessary for the welfare of my minor child while said child is under the care of Kirsten Rachon Blankenship and Wesley A.Blankenship, owner and operator of Fox Island Equestrian if I am not reasonably available by telephone at the following number TBD to give consent. 


Parent/Guardian Phone Number:

This authorization is effective from (date)

This authorization is effective to (date)

During a medical emergency, my preferred hospital is

however if that hospital is unavailable my second choice is

This consent form should be taken with minor child to the hospital/urgent 

Additional information will assist in treatment:


Family address:

(Cell) Telephone: Parent 1

(Work) Telephone: Parent 1

(Cell) Telephone: Parent 2

(Work) Telephone: Parent 2
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*

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

This consent form should be taken with the participant to the hospital/urgent

Additional information will assist in treatment:


Last Tetanus:

Allergies to medications or over the counter medications:

Allergies to food:

Below area is to share any special request, current medications, blood type or pertinent information for medical staff?

Primary Physician:

Physician's Telephone:

Insurance:

Policy #:

Policy Primary Card Holder:
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!