Release forms - 1 of 4

RIDER'S REGISTRATION AND RELEASE FORM

Registration
Client: black line
Date of Birth: black line
Age: black line
Street Address: black line
City: black line
State & Zip: black line
Home Phone: black line
Work Phone: black line
Parent/Guardian: black line
Home Phone: black line
Work Phone: black line
School or institution
presently attending:		 black line
In case of emergency,
Contact 1: black line
Phone: black line
Contact 2: black line
Phone: black line
 
Photo Release (optional)
I hereby consent to and authorize the use and reproduction by PAL-O-MINE EQUESTRIAN, INC., of any and all photographs and other audiovisual materials taken of me/my son/daughter/my ward for promotional printed materials, educational activities or for any other use for the benefit of the program.
Client, parent or
guardian's signature:		 black line
Date: black line


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Pal-O-Mine Equestrian, Inc. • 829 Old Nichols Road • Islandia, NY 11749