Pg. 2 Volunteer Information

Child's name: ___________________________________________________

Date of birth ___________________________________________________

Mother's name________________________ Father's name _____________

Emergency Phone numbers__________________________________________

Does your child have any allergies or medical condition that I need to be aware of? 
_____________________________________________________________________________

_____________________________________________________________________________

Name of Pediatrician_____________________________________________

PARENTS PLEASE READ THE FOLLOWING CAREFULLY AND SIGN. OUR SAFETY RECORD HAS BEEN ALMOST FLAWLESS SINCE OPENING IN 1993, BUT THERE ARE ALWAYS POSSIBILITIES OF INJURY WHEN WORKING AROUND HORSES.

I, _______________________(print parent's name) have carefully read the rules for my child to volunteer at Ponyland. I also understand that safety is a priority at Ponyland. I understand that there are hazards that are related to this position which include but are not exclusive to the following: Falling off a horse, being bitten or kicked, tripping over fixed obstacles such as the ropes that divide the pony ride ring, objects on the ground, sharp tools, insect bites, scratches and bruises etc. I will not hold Ponyland responsible for accidents or injury on or off Ponyland property in any way. In the event an accident or injury does occur, I authorize the owner of Ponyland, Donna Isenhower to administer first aid or give permission to a physician, nurse or hospital to administer normal emergency medical care, as they deem necessary in the interest of my child.

I have read these warnings and sign this liability waiver with full understanding of its contents

Parent signature _________________________________________ Date _____________________

OFFSITES: Parents, we occasionally take ponies to other locations for parties, company picnics etc. We assign a certain number of volunteers to go with the adult in charge to the location to help walk with the ponies etc. Please choose one response below and sign next to it.

YES, my child has permission to participate in offsites_________________________________(parent 
signature)

NO, my child does not have permission to participate in offsites _________________________________(parent signature)