https://docs.google.com/forms/d/e/1FAIpQLSe68j7MwztV63NXnYaLkG_2keq8KFXvd7LJcFWAOrLHIFul-w/viewformBrooke's Round Up Registration FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Participant's Name *FirstLastParticipants date of birth *Parent/Guardian Name *FirstLastParent/Guardian Relation to Participant *Parent/Caretaker/Group Home, etcMailing Address *Please list the address where the participant resides.Telephone Number *Telephone NumberEmail Address *Emergency Contact Name *Emergency Contact Phone Number *We require an Emergency contact in addition to the number where the participant resides.Number of Guests Attending with Participant *Parents, siblings, family, etc.Please indicate the participant's special need(s)/disability *Does the participant require the use of ambulatory aids?YesNoIf you answered "YES" to the question above please indicate what type of ambulatory aids. *If you answered No, please put N/AParent/Guardian Electronic Signature *By typing your name here, you agree that this electronic signature is made by the parent/guardian and that it is as binding as a written signature.Electronic Signature Date *Photo Release *I agree and give my permissionI do not agreeI give consent to and authorize the use and reproduction by Blazin' Trails Cowboy church and any and all photographs and any other audio/visual taken of the participant for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.Liability Release *I HAVE READ THE BELOW RELEASE IN FULL AND AGREE TO THE TERMSUnder North Carolina law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in equine activities resulting exclusively from the inherent risks of equine activities. Chapter 99E of the North Carolina General Statutes." I acknowledge that there are inherent dangers and risks in horseback riding and in being around or working with horses. I realize that I/my child could sustain injuries including life threatening injuries while engaging in horseback riding or while being around or working with horses I am willing to accept these risks. I agree to indemnify Roy Blanton, Blazin’ Trails Cowboy Church, Jumpin' Jacks Party Rentals, from any and all claims, demands, suits, or liability which may be brought against them by others as a result of injuries sustained by myself/child while riding at the facilities and while riding or working with their horses in any way. I acknowledge it is the rider’s responsibility to wear protective headgear while mounted. It has been recommended to me that the protective headgear meet the A.S.T.M. (American Society for Testing Materials) standard and display the SEI (Safety Equipment Institute) seal. Roy Blanton, Blazin’ Trails Cowboy Church, Jumpin' Jacks Party Rentals, its employees and/or representatives make no representation or warranty expressed or implied about any protective headgear and cautions riders that serious injury and death may result despite wearing such headgear as all equestrian sports involve inherent risk and that no protective helmet can protect against all foreseeable injury. I acknowledge that it is the rider’s responsibility to wear appropriate footwear while on the premises of Blazin’ Trails Cowboy Church. I agree to wear this footwear whether mounted or on the ground. This footwear will include shoes/boots and socks. Shoes or boots will have a flat tread sole, a 1” heel, and a fully enclosed upper. Boots or shoes designed for the purpose of equestrian activity are preferred but not required. I acknowledge that it is the rider’s responsibility to wear appropriate clothing which will include but not be limited to full length pants and minimal jewelry. I understand that Blazin' Trails Cowboy Church accepts no liability for injury or damage to clothing/jewelry or injury caused by clothing/injury and reserves the right to request that I change clothing/jewelry that is deemed unsafe. I ACKNOWLEDGE that I have read the above release in full and release Roy Blanton, Blazin’ Trails Cowboy Church, Jumpin' Jacks Party Rentals, of all liability relating to the activities that I have chosen to participate in.Submit
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June 15, 2025
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