Deerfield Ruritan Trail Ride, Sept. 19 - 21, 2008
Application
Deadline for application: Sept.5, 2008
Please complete a separate form for each person
NAME_______________________________________________________
ADDRESS____________________________________________________
______________________________________________________
PHONE (______)_____________________
EMERGENCY NAME__________________________________________
EMERGENCY PHONE (______)________________
REQUIRED: COGGINS TEST NO______________________ STATE ______________
CHECK ONE: ___Rider($75) ___Non-Rider($75) ___Child(12 or under - $40)
E-MAIL (PRINT CLEARLY!)______________________________________ ___Vegetarian
Waiver:
I hereby enter the Deerfield Ruritan Trail Ride at my own risk. I understand 1) that trail
riding can involve being in remote areas for extended periods of time, far from communications,
transportation and medical care 2) that these areas may have many natural hazards which ride
management cannot anticipate, eliminate or control 3) that horses can be excitable,
unpredictable and difficult to control 4) that accidents can happen to anyone at any time and
may result in severe injury or death. I do hereby release today and forever The Deerfield
Ruritan Club, ride personnel, private land owners and the National Forest Service from any
suits or charges resulting from any accidents or losses, either caused by me or my horse, or
to me or my horse or equipment. I HAVE READ AND UNDERSTAND THIS LIABILITY RELEASE.
Signature __________________________________________ Date________
Parent/Guardian of minor _____________________________
Accompanying adult_____________________________
Checks to: Deerfield Ruritan Club.
Mail to: Pat O'Neil, 3409 Hite Hollow Rd., Deerfield, VA 24432
REMEMBER: NO APPLICATION ACCEPTED WITHOUT COGGINS TEST COPY!