Are you a student taking lessons or a guest on the property? (select one) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Student Informaiton

Rider {binding ItemNumber}

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

DOB {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Riding Experience (check one) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Additional Riding Experience Info (Optional) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Lesson Information

Your lesson agreement is subject to the following fees:
1 Hour Private Lesson - $80
1 Hour Semi-Private Lesson (2-3 riders) - $65
1 Hour Group - $55
1 1/2 Hour Private Lesson - $65
1 1/2 Hour Semi-Private Lesson (2 - 3 riders) - $45

One rescheduled lesson per month will be allowed. The lesson may be rescheduled due to illness, planned vacation, etc.

Please Select Your : Lesson Type, Day/Days, and Time

Lesson {binding ItemNumber}

Lesson

Lesson Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Day {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Time {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Payment Information & Agreement

Preferred Email for Monthly Invoice {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Lesson Start Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Payment Agreement {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Parent Information

Parent / Guardian {binding ItemNumber}

Parent / Guardian {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Home # {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Cell # {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Work # {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Emergency Information

Emergency Contact {binding ItemNumber}

Emergency Contact {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Relationship {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medical Information

Medical History (please mark all the following that apply to camper) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If "Yes" to any of the above, please explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Allergy History {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please list the allergen and describe the allergic reaction: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Physician & Insurance Information

Doctor's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Hospital Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

I / We agree that: Should medical treatment be required, I and/or my medical insurance shall pay for ALL such incurred expenses.

Do you have Medical Insurance currenlty? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

My Medical Insurance Company is {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Policy # {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Hold Harmless Authorization for Pediatric Emergency Medical and/or Surgical Treatment

For the safety of Children, sound medical practice calls for this authorization. In emergencies, where the Parent/Legal Guardian or Emergency Contact of the Child cannot be reached - this form will be extremely important. The authorization granted by this form will be used only when absolutely necessary and only after every attempt has been made first to contact the Parent/Legal Guardian or Emergency Contact.

I hereby give my permission for my Child to attend Bee Cave Riding Center LLC “Camp”. The Child herein described has permission to engage in all prescribed camp activities except as noted.

I hold harmless Bee Cave Riding Center LLC, and/or Riding Horses with Kathy Slack, LLC, and their employees, agents, servants and volunteers from all risk, liability, injury, damage and loss to all persons and property which may occur to my child during or resulting from participation in the program.

I hereby authorize Bee Cave Riding Center LLC, and/or Riding Horses with Kathy Slack, LLC to take measures in the event of a medical emergency. I hereby give permission to the medical personnel selected by Bee Cave Riding Center LLC, and/or Riding Horses with Kathy Slack, LLC to order X-rays, routine tests, treatment, and necessary related transportation for my child.

In the event I cannot be reached in an emergency, I hereby give permission to the Physician of the hospital selected by Bee Cave Riding Center LLC, and/or Riding Horses with Kathy Slack, LLC to secure treatment, including hospitalization, for my Child as named above.

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Photo / Video Agreement

Untitled {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Waiver & Release

Registration of Participant and Agreement {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Friendly Reminders - Rules & Regulations {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Protective Headgear {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Release of Liability {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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WARNING: Under Texas Law (Chapter 87, Civil Practice and Remedies code) an Equine Professional is not liable for any injury to or the death of a participant in equine activities resulting from the inherent risk of equine activities.

I HEREBY CERTIFY THAT I HAVE READ & UNDERSTAND ALL OF THE FOREGOING TERMS OF THIS AGREEMENT & EXPRESSLY ASSENT THERETO.

Signature of Parent / Guardian {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Send a copy of this form to this email ------->

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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