Confidential Riding Application and Medical History Form

Personal Details



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

Riding Experience:

The number of times the rider has ridden in the last 12 months Indicate below the number of times the rider has ridden in total

Emergency Contacts

Medical History

NO (Please tick if applicable)

Please tick: Any pre-existing medical or other condition that may affect or risk other persons or myself

Back Injury
Heart Condition
Blood Condition
Uneven Pupils
Allergic Reactions
Recent Injury

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

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.

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