Buckle Up Bushrides Booking & Confidential Riding Application Name Riders Name * Contact Number * Over 18 (check box) Age: (if under 18) Email * Ride Description and Date * Approx Weight * Under 60kg 60kg - 75kg 75kg - 90kg Height * Riding Experience * Experienced Intermediate No Experience / Beginner The number of times the rider has ridden in the last 12 months * Have you ridden with us before? * Yes No If yes, name of the horse ridden I agree to the following: * I will only ride the horse in a safe and controlled manner I will wear an Australian Standard Approved helmet and the correct footwear at all times I will read and follow all signs on the property and follow all instructions The Instructor/Guide may cancel my ride without refunding any fee if I do not comply with any of these terms and conditions Indicate below the number of times the rider has ridden in total * 0 - 10 (Little experience) 10 - 20 (Some experience) 20 - 50 (Average experience) 50 - 100 (Experienced) 100 + (Very experienced) In the case of any emergency the following information is intended to assist: Name and telephone numbers of contact people. ** Legal guardian details must be provided if rider is under 18 years of age Emergency contact name * Relationship with Rider * Mobile * Home * Work * Do you (or your child) suffer from any of the following? No (Please tick if applicable) Please tick: Any pre-existing medical or other condition that may affect or risk other persons or myself. Asthma Diabetes Epilepsy / Fits Fainting Blackouts Disability Back injury Heart Condition Blood Condition Pregnancy Dizziness Migraines Uneven Pupils Medications Allergic Reactions Recent injury Other (Describe) Allergies Please describe allergy and reaction Tetanus Immunisation It is particularly important that people dealing with horses are immunised against tetanus. Tetanus is normally given at five years of age as Triple antigen or CDT and at fifteen years of age as ADT. Year of last tetanus immunisation * Medication Is it necessary for you or your child to carry their own medication at all times? * Yes No Name of drug: Frequency: Dosage: Consent To Medical Attention I authorise the instructor in charge to administer first aid and call an ambulance. I agree to bear any cost thereby incurred. I agree to the terms and conditions Click here to read Terms and Conditions. I agree to the Terms and Conditions I Agree Rides Weekend rides $810 How did you first hear about us? Friend Internet Website Facebook Return Guest Other Do you have any special dietary requirements/comments/questions Privacy Statement – Privacy Act 1998 By completing this form you are supplying the Provider with personal information about yourself. This information is needed to ensure your safety during your time with us. The Provider is required to collect this information by our insurance company and by the department of Workplace Health and Safety. This information you provide will not be supplied to any other organisation or used for any other purpose than that which is stated above
