PINEBROOK FARMS HORSEMANSHIP CAMP/CLINIC REGISTRATION
 
NAME OF PARTICIPANT:
Date(s) of session(s) attending: _____ /_____ /______ thru _____ /_____ /_____ and ______ /______ /______ thru ______ /______ /_____
Male or Female, Age (at time of camp) ________ Height _______ Weight _______ Birth date: _________ / ____________ / ____________
Address:____________________________________________City:____________________________ State ________ Zip __________
Name of parents or guardian of minor_____________________________________________________________________ camper______________________________________________________________________________________________________
Home phone:( ___ ) _____ - _____ Ms. work: ( _____ ) _____ - ______ Mr. work: ( ____ ) _____ - _______ Fax:( ____ ) _____ - _________
Emergency contact (other than camper’s parents ) _________________________Telephone No.( ____ ) ____ - _______ Relationship to participant:
School District: ____________________________________________ Learned about camp from:
Camper would like to bunk and/or ride with, a friend, attending this session.
Experience with horses*
Will participant be riding English or Western style? _______________ Is participant bringing his/her own horse? ______________ Own tack?
If so, please describe the horse briefly as to sex, (no stallions allowed), age, size, disposition, training, etc.*
(Owner of horse will need to sign a form releasing Pinebrook Farms from any liability.)
Pinebrook Farms participant in prior years?______ How many?______ Suggestions and/or comments concerning program:
(*Use reverse side if necessary)
CAMPERS: Please request a Health History Form #FMO8 by phone or e-mail. Registration is contingent upon receipt of the Health History form, which certifies that camper has been examination by a physician within 12 months of camp date. NOTE: This form is not required for our overnight clinics.
RELEASE/AUTHORIZATION FORM
I am participating/am allowing my child,___________________________________________________to participate in Pinebrook Farms' summer camp/clinic with the understanding that I will not hold Pinebrook Farms, Jorine or Harlie Seale, their family or employees, liable for any accident or injury to me/my child, any person accompanying me/my child, or to mine/my child's horse, while on the premises of Pinebrook Farms or while in the care of the above stated. Nor will I hold the above responsible for any loss of, nor damage to tack, clothing or equipment left at Pinebrook Farm due to accident, theft or fire. I give my permission for any photograph/s or videos taken of me/my child, during camp/clinic, to be used for promotional purposes without compensation.
I understand and agree that: These activities will be on a working horse ranch, and on and around horses. I realize that even under well supervised conditions, there is still risk involved. Horseback riding is classified as rugged adventure recreational sport activity, and that there are numerous obvious and non-obvious inherent risks always present. Horses are 5 to 15 times larger, 20 to 40 times more powerful, and 3 to 4 times faster than a human. If a rider falls from a horse to ground it will generally be at a distance of from 3 1/2 to 5 1/2 feet, and the impact may result in injury to the rider. Pinebrook Farms chooses lesson horses for their calm dispositions and sound basic training, as is required for use as riding horses for novice and beginning riders, and Pinebrook Farms follows a rigid risk reduction program. Yet, no horse is a completely safe horse. If a horse is frightened or provoked it may divert from its training and act according to its natural survival instincts which may include, but are not limited to: stopping short, changing directions or speed at will, shifting it’s weight, bucking, kicking, biting, or running away from danger.
WARNING:  Efective September 1, 1995, Texas State Law (Chapter 87, Civil Practice and Remedies Code) states that; "An equine professional is not liable for an injury to or the death of a participant in equine activities resulting from the inherent risks of equine activities".

Signature of participant/parent or legal guardian of minor child
THIS FORM MUST BE NOTARIZED BEFORE THE CAMPER CAN BE REGISTERED (not required for clinic participants).
Subscribed and sworn to before me, the undersigned authority, on this__________ day of ___________ /________.
Signature of Notary
Notary Public in and for: __________________________________________ County, State ______ My commission expires:______ / _____ / _____
A NON REFUNDABLE REGISTRATION FEE OF $200.00 must accompany this form.
Sorry, we cannot accept payment by credit Cards
Please make check or money order payable to: Pinebrook Farms - 611 Virgie Community, Magnolia, TX 77354-3932
Phone 281-356-3441 - Fax 281-356-7018 - E-Mail Address: jorine@pinebrook-farms.com