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Membership |
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lake country horsemen’s association |
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Tunison Road, Interlaken |
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Veronica & Rick Leisenring Or: Leslie & Dean Hendrix (607) 532-4342 3028 Darling Road Interlaken, NY 14847
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Name of Applicants:
Mailing Address:
City: State: Zip Code:
Phone #: E-Mail Address:
Name of Children under the age of 18 if this is a Family Membership:
Type of Membership & Prices:
Individual Membership(for the above applicant only) Date Paid: _________________________ Prepaid before or on May 1st, 2010 $20.00 □ Paid after May 1, 2010 $30.00 □
Family Membership (all children need to be under age of 18yrs.) Date Paid: _________________________ Prepaid before or on May 1st, 2010 $25.00 □ Paid after May 1, 2010 $35.00 □
An annual liability release must be signed as a part of LCHA membership, see the back of this form. Please note that the liability will cover all persons listed on this application form. If anyone accompanies you to a show that is not under this membership, they will have to sign a liability from each time they participate.
Please fill in the complete application. Remember to sign the back of this form. Please Read Carefully Before Signing.
Event Sponsors and Club Administrators Do Not Assure Your Safety!
Please Initial (a parent or legal guardian must initial if the participant is under the age of 18):
___________ I acknowledge that I, The Participant, Parent or Legal Guardian, will be responsible for any (Initial) and all costs incurred by the participant or the participant’s family members for injuries or property damage that I or my family may incur, and that I, The Participant, Parent or Legal Guardian, have accident medical insurance coverage in force for injuries that I or my family may incur.
__________ I acknowledge that I, The Participant, Parent or Legal Guardian, will be responsible for my (Initial) negligent acts, the negligent acts of my family members and/or legal wards and animals, and that I, The Participant, Parent or Legal Guardian, do carry personal liability insurance coverage now in force.
__________ I acknowledge that I, The Participant, Parent or Legal Guardian, should purchase and wear (Initial) ASTA standard/SEI-certified equestrian helmets while participating in equine activities. I understand that the wearing of such headgear while participating in equine activities may reduce the severity of some of the participants head injuries in the event of a fall or other related accident.
__________ I acknowledge that I, The Participant, Parent or Legal Guardian, participate in this event (Initial) totally at my own risk for injuries or property damage I or my family may incur and I acknowledge that I, The Participant, Parent or Legal Guardian, et al, hereby release and hold harmless the sponsor, co-sponsors, their owners, their officers, directors, members, affiliated organizations and others acting on its behalf, from any claim, legal liability, legal action or right for damages, for any accident which may occur to me or my equine animal. I also assume and accept full responsibility for any damages done by me or my equine animal at this show, activity and/or event.
I, The undersigned, Participant, Parent or Legal Guardian, being of legal age, have read, understand and initialed the above agreement and release.
Signature of Participant (if 18yrs or older), Parent or Legal Guardian(if participant is under 18yrs old):
X:
Date:
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