Statesman Farm
Information and Registration
Please fill out both sides of form in its entirety and sign back; if less than 18 a parent or guardian must sign.
Student Full Name: Nickname:
Student DOB:
Contact Information:
Contact Name: Phone:
Address: Cell #:
Work #:
Email:
Emergency Contact Information:
Contact Name: Phone:
Address: Cell #:
Work #:
Email:
Secondary Contact Information:
Contact Name: Phone:
Address: Cell #:
Work #:
Email:
Medical Information
Please list any existing conditions which should be considered:
Please list any medications currently being taken:
Equine Experience:
Please describe any previous horse/riding experience:
Please describe any problems/ incidents you might of have had:
Medical Release:
I do hereby authorize Statesman Farm to take such action as perceived as necessary in the event of an accident in which the emergency contacts on the reverse side of this form cannot be reached. Such action could include, but is not limited to, emergency transport to a hospital or other medical care facility.
Signed: For:
Printed Name: Date:
Registration Type: (Check all that apply)
____ New _____Student
____Update _____Boarder
_____Employee
_____Working Student