Mesa Farm                                                                        dale.mesafarm@gmail.com

Dale Perkins                                                                      www.daleperkinshorseshow.com

67 Muschopauge Road                                                      508-886-6898

Rutland, MA 01543                                                           774-437-1805 (cell)

 

 

Under Massachusetts Law, an Equine Professional is not liable for an injury  to, or the death of, a participant in equine activities resulting from the inherent risks of equine activities, pursuant to Chapter 128, Section 2D of the General Law.

 

RELEASE OF LIABILITY

 

 

            This is an AGREEMENT made this _________ day of ____________, 20___

 

By and between Dale Perkins of Mesa Farm, Rutland, MA and:

 

 

 _______________________________ (participant)   _______________(phone number).

 

 

WHEREAS, ______________________ (participant) is desirous of participating in riding and other horsemanship activities at Mesa Farm.

 

WHEREAS, the participant understands that working around and riding horses can be dangerous due to the unpredictability and size of horses and that horses can inadvertently seriously injure and/or kill people and that people can be thrown while riding, all causing person(s) serious injury.

 

Now, therefore, for mutual consideration, the participant covenants and agrees that Dale Perkins and Mesa Farm shall in no way be liable to the participant, his or her heirs, executors or assigns for any damage or redress in any form for any injuries fatally or otherwise caused to or sustained by the participant because of accident from any cause whatsoever while engaged in any capacity while involved with programs at Mesa Farm and/or the Dale Perkins Horse Show.  The participant further covenants and agrees to indemnify and behold Dale Perkins or Mesa Farm from any loss that may result from any claim, suit or legal action brought by the student and/or his/her heirs, executors, administrators, or assigns.

 

WITNESS our hands and seals on the day and year first written above,

 

            By __________________________ Dale Perkins

 

            _____________________________ (participant/legal guardian)

 

 

 

 

 

 

 

Emergency Medical Information

 

 

Where parents or close friends can be reached during time participating at Mesa Farm

 

Name__________________________________  Phone_________________________

 

Medical Insurance Policy_________________________________________________

 

Doctor’s Name___________________________Phone_________________________

 

Note:  Special medical problems which should be known in case of an emergency:  allergy to medication (i.e. penicillin) or bee stings, and routine medications (i.e. insulin) should be noted.

 

Please list: _____________________________________________________________

 

Medical treatment release:

I give my consent for emergency medical treatment/aid in case of illness or injury during my participation with Mesa Farm activities.  This authorization includes x-rays, surgery, hospitalization, medication and any treatment deemed “life saving” by the physician.

 

 

Participant or parent/legal guardian                            Date

 

 

 

I DO NOT give my consent:

 

 

 

Participant or parent/legal guardian                            Date