Camp Release form

WM. R. HEBERLE STABLES, INC.

751 BROWNCROFT BLVD.

ROCHESTER, NY 14625 - 482-1290 / 654-9027

RELEASE OF LIABILITY

The undersigned acknowledges that the handling and riding of horses is hazardous to both rider and horse and therefore willingly and knowingly accepts whatever risks are involved while riding on the premises of William R. Heberle Stables, Inc. The understanding hereby releases instructors at William R. Heberle Stables, Inc. and/or William R. Heberle and/or William R. Heberle Stables, Inc. from all liabilities arising out of any occurrence which result in injury, loss and/or damage to the student, horse and/or equipment. Additionally, the undersigned prohibits any relative, representative and/or agent from seeking relief for damages from instructors at William R. Heberle Stables, Inc. and/or other instructors and/or William R. Heberle and/or William R. Heberle Stables, Inc. on behalf of the undersigned.

Print parent or guardian name : ______________________________

Date : ______________

Signed, parent or guardian for student under age 18:_______________________________Date: _______________

Student's Doctors Name : _______________________________Phone number: _______________

NAME:________________________________________________________

ADDRESS:_____________________________________________________

_____________________________________________________

PHONE NUMBERS:____________________________________

EMAIL ADDRESS:______________________________________________

CAMP WEEK_________________________ FULL / HALF DAY___________

PAYMENT AMOUNT:______________________ CHECK #:__________

NO REFUNDS

DATE OF BIRTH OF CHILD__________________________

ADDITIONAL INFORMATION; allergies, intolerance's to food

Day:__________

Time:_________

Last Updated Wednesday, April 26 2006 @ 07:10 AM EDT