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atMillstone Farm

Quinton, VA


USERL Charity Trail Ride

Rain Date October 17, 2010

Registration Form

Please fill out and mail the following application to join us on the trail ride before

October 10, 2010 10:00amOctober 1st, 2010.

Rider Name_____________________________________________________________

Address________________________________________________________________ ________________________________________________________________

Phone (_______) _________________


Emergency Contact __________________________________

Emergency contact # for rider (_______) _________________

Horses Name: _______________________________ CogginsSent:

Horses Name: _______________________________ CogginsSent:

Rider(with lunch) ___________________ $35

Lunch Only (no riding) _______________ $10

Poker Run Participant________________$10 (additional)

Donation to USERL __________________

Total Amount Enclosed $ ______________. 00

Make check payable to: USERL

Mail to: USERL Trail RideC/o Pam Graham4575 DarbytownRoadHenrico, VA 23231

Phone: 804-240-1196

E-Mail Pam at

Click HEREfor the Waiver form that must be signed and mailed in as well.


Please Print and fill out the following release form to join us on the USERL Benefit trail ride, 10/10/10. Rain Date 10/17/10

The sponsors of this equine activity, as well as equine professionals, organizations, volunteers or any other persons, shall not be liable for an injury to or death of a participant resulting from the intrinsic dangers of equine activities.

No participant, nor any participant's parent, guardian or representative shall have or make any claim against or recover from any equine activity sponsor, equine professional or any other person for injury, loss, damage, or death of the participant resulting from any of the intrinsic dangers of equine activities.

"Intrinsic dangers of equine activities" means those dangers or conditions that are an integral part of equine activities, including by not limited to (i) the propensity of equines to behave in ways that may result in injury, harm or death to persons on or around them; (ii) the unpredictability of an equine's reaction to such things as sounds, sudden movement, and unfamiliar objects, persons, or other animals; (iii) certain hazards such as surface and subsurface conditions; (iv) collisions with other animals or objects; and (v) the potential of a participant acting in a negligent manner that may contribute to injury to the participant or others, such as failing to maintain control over the equine or not acting within the participant's ability.

In consideration of the sponsor allowing me (or my child) to attend this event, I agree to assume all risks specifically enumerated herein. I UNDERSTAND THAT THIS MEANS THAT I AGREE NOT TO SUE ANY OR ALL OF THE RELEASED PARTIESin connection with the event.

This waiver shall remain valid unless expressly revoked in writing by the participant or parent or guardian of a minor.

Print Name ____________________________________________

Signed _______________________________________________

Date ___________________________

If participant is under 18, print name of parent/legal guardian

Print Name ____________________________________________

Signed _______________________________________________

Date ___________________________


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