This form needs to be filled out by ALL
RIDERS. For anyone who wishes to ride at the Rockin' P Ranch please print and
completely fill out this form. Any rider who is under the age of 18 MUST have a
Parent or Legal Guardian sign this Liability Waiver Form.
hereby known as “UNDERSIGNED”,
do hereby affirm and acknowledge that I/We have been fully informed of the
inherent hazards and risks associated with “ACTIVITIES” in which I/We or the
minor(s) for which I/We claim full responsibility.
“ACTIVITY”
and/or “ACTIVITIES” Inherent hazards and risks include but are not limited to:
1.
Risk of injury from the “ACTIVITY” and equipment utilized in an “ACTIVITY” is
significant including the potential for permanent disability and even death.
2.
Possibility equipment failure and/or malfunction of my/our own or other’s
equipment.
3.
My/Our own negligence and/or the negligence of all others, including but not
limited to, owners, officers, employees, agents, independent contractors,
volunteers, clients or any representative of the Rockin’ P Public Riding Ranch,
Inc. and the Pekin Park District, including but not limited to operator error.
4.
The propensity of any type of horse, mule, donkey, hereby known as equine,
to behave in dangerous ways that may result in injury,
regardless of the equine’s previous
training and past performance.
5. The
inability to predict an equine’s reaction to sound, movements, unfamiliar
environment, objects, persons, or animals.
6.
Natural hazards including but not limited to surface or subsurface conditions.
7. Propensity
for an equine to run, buck, bite, kick, shy, stumble, rear, trample, scratch,
peck, fall, make unpredictable movements, spook, go down, jump, butt, step on
person’s feet, push or shove without warning or apparent cause.
8.
Saddles or bridles that loosen or break which may cause the participant to be
jolted or fall.
9.
The equine may also react in a dangerous manner when a condition or treatment is
considered hazardous.
10.
The potential for any participant to fail to exercise reasonable care, take
adequate precautions, or use adequate control when engaging in an animal
“ACTIVITY”, including failing to maintain reasonable control of the equine or
failing to act in a manner consistent with the person’s abilities.
11.
Collisions with trees, brush, and other animals or objects.
12.
Broken bones, severe injuries to the head, neck and back which may result in
severe impairment or even death.
13.
Cold weather and heat related injuries and illness, including but not limited to
frostnip, frost bite, heat exhaustion, heat stroke, sunburn, hypothermia and
dehydration.
14.
Exposure to outdoor elements, including but not limited to rock fall, inclement
weather, thunder and lighting, severe and/or varied wind, temperature and all
other weather conditions.
15.
Attack by or encounter with insects, reptiles, deer and/or other animals.
16.
Accidents or illness occurring in remote places where there is no or delayed
medical response or facilities.
17.
Fatigue, chill, and/or dizziness, which may diminish reaction time and increase
the risk of accident.
18.
Sense of balance, physical coordination, and ability to follow instructions.
I/We
understand these risk descriptions are not complete and unknown or unanticipated
risk may result in injury, illness or death.
I/We
declare myself/ourself and/or the minor(s) for which I/We claim full
responsibility, do not and have not suffered from any form of mental or physical
medical conditions which I/We understand may lead to a dangerous situation with
regards to other persons or myself/ourself during “ACTIVITIES”.
I/We also understand that no one is
permitted to ride a horse, pony, mule if pregnant.
In
consideration for being permitted to participate in any way in “ACTIVITIES”, I
hereby agree, acknowledge and appreciate that:
1.
I/We, the “UNDERSIGNED”, HEREBY RELEASE AND
HOLD HARMLESS THE ROCKIN’ P PUBLIC RIDING RANCH AND
PEKIN PARK DISTRICT including, but not limited to, their owners, officers,
employees, agents, independent contractors, volunteers, clients or any other
representative - hereby known as “RELEASEES”, WITH RESPECT TO ANY ANDALL
INJURY, DISABILITY, DEATH, or loss of damage to person or property, WHETHER
CAUSED BY NEGLIGENCE OR OTHERWISE.
2.
I/We, the “UNDERSIGNED”, release the “RELEASEES” from liability and
responsibility whatsoever and for any claims or causes of action that my/our
estate, heirs, survivors, executors, or assigns may have for personal injury,
property damage, or wrongful death arising from the “ACTIVITIES” whether caused
by active or passive negligence of the “RELEASEES” or otherwise.By executing this document, I/We agree to hold the “RELEASEES” harmless
and indemnify them in conjunctions with any injury, disability, death, or loss
or damage to person or property that may occur as a result of engaging in
“ACTIVITIES”.
3. By entering into this Agreement, I/We, the
“UNDERSIGNED”, I/We are not relying on any oral or written representation of
statements made by “RELEASEES”, other than what is set forth in this Agreement.
This
release shall be binding to the fullest extent permitted by law.If any provisions of this release are found to be unenforceable, the
remaining terms shall be enforceable.
Page 1 of 2(TURN OVER)
I/We, the “UNDERSIGNED”, HAVE READ
THIS RELEASE OF LIABILITY AND
ASSUMPTION OF RISK AGREEMENT, AND
I/We FULLY UNDERSTAND ITS TERMS, AND
UNDERSTAND THAT I/We HAVE GIVEN UP LEGAL RIGHTS BY SIGNING IT AND
I/We SIGN IT FREELY AND
VOLUNTARILY WITHOUT ANY INDUCEMENT.
X
Print Name and Sign:
_____________________________________________________________________________Date___________
“UNDERSIGNED” Adult #1
X
Print Name and Sign:
_____________________________________________________________________________Date___________
“UNDERSIGNED” Adult #2
FOR MINOR PARTICIPANTS -
Under Age 18: This is to certify that I, the
“UNDERSIGNED”, as Parent, Guardian, Temporary Guardian with legal responsibility
for this participant(s), do consent and agree not only to his/her release of all
“RELEASEES”, but also to release and indemnify “RELEASEES” from any and all
liabilities incident to his/her involvement in these “ACTIVITIES” for myself, my
heirs, assigns, and next of kin.
Minor(s)
Full Names(s)
______________________________________________________________________________________________
X
Print Name and Sign:
_____________________________________________________________________________
Date____________
“UNDERSIGNED” Parent/ Legal Guardian
This
release shall be binding to the fullest extent permitted by law.If any provisions of this release are found to be unenforceable, the
remaining terms shall be enforceable.
PROTECTIVE
HEADGEAR REFUSAL
ANYONE UNDER AGE
16 MUST WEAR A HELMET
I/We, the “UNDERSIGNED”, for myself/ourself
and/or on behalf of my/our child or Legal Ward, have been fully warned and
advised by Rockin’ P Public Riding Ranch, Inc. that we should wear a properly
fitted helmet in order to reduce some or all of our head injuries as the result
of a fall or any other occurrence associated with this Hazardous “ACTIVITY”.
I/We realize that we are subject to
injury from this “ACTIVITY” to which we are exposing ourselves purely
voluntarily.I/We, the
“UNDERSIGNED”, also agree to release and indemnify the “RELEASEES” from any and
all liabilities incident to my involvement in these “ACTIVITIES” for
myself/oursefl, my/our heirs, assigns and next of kin.
AGAINST
THIS ADVICE, I/WE ARE
REFUSING THIS CRITICAL SAFETY PRECAUTION.
I/We, the “UNDERSIGNED”, have read this
foregoing statement and do understand its warnings and assumption of risks.
X
Print Name and Sign:________________________________________________________________________________Date_________
“UNDERSIGNED” ADULT #1
X
Print Name and Sign:________________________________________________________________________________Date_________
“UNDERSIGNED” ADULT #2
FOR MINOR PARTICIPANTS
-Ages of 16 or 17 (ALL
other Minors MUST wear a Helmet):
This is to certify that I, the “UNDERSIGNED”, as Parent, Guardian, Temporary
Guardian with legal responsibility for this Minor, do consent and agree not only
to his/her release of “RELEASEES”, but also to release and indemnify the
RELEASEES from any and all liabilities incident to his/her involvement in these
“ACTIVITIES” for myself, my heirs, assigns and next of kin.
MINORS(s)
full name(s)
_____________________________________________________________________________________________
Print
Name and Sign:
_________________________________________________________________________________Date___________
“UNDERSIGNED” Parent/ Legal Guardian of Minor(s) listed above
This
release shall be binding to the fullest extent permitted by law.If any provisions of this release are found to be unenforceable, the
remaining terms shall be enforceable.
WARNING:Following is the Illinois
Equine Activity Act 745 I.L.C.S. 47/1:
Under the Illinois
Equine Activity Act, each participant who engages in an equine activity
expressly assumes the risk of engaging in and is legal responsibility for
injury, loss, or damage to person or property resulting in the risk of equine
activities.
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of 2
Please, ALWAYS initial and sign where
indicated by a red arrow. If signing for a minor also fill out the
yellow highlighted area.
BRINGING IN YOUR OWN HORSE?
Planning on hauling in your own horse for
the day? Please print and fill out this form prior to arrival. April-October,
Thursday-Sunday, Weather permitting only. All horses require a negative coggins
and a $5 fee. Trailer in horses will not be permitted to ride with our line
horses.
Waiver's and Forms
PLEASE
READ 
