Date ___________  Ride Fee = $27.00  per adult rider  or  $20.00 per junior (18 years & under)

 

Extra Meals  = $  5.00  each    #____@ $5  = $_______   TOTAL AMOUNT DUE $ ______________

 

 

NAME OF RIDER_________________________________________________________________

 

NAME OF HORSE________________________________________________________________

 

Complete Mailing Address__________________________________________________________

 

_________________________e-mail ______________________Phone______________________

 

Please supply a phone number and/or e-mail address so we may contact you if necessary

Cell Phone number if you carry one on the trail ________________________________

 

Mileage Choice =  ___Long Loop   ____Short Loop   (notify ride management if changed)

 

Member of NEW HAMPSHIRE HORSE & TRAIL ASSOCIATION ? ____________

 

Member of New England Horse & Trail ? ______  NEHT Rider # __________  Horse #__________

 

 

WAIVER OF LIABILITY

 

Every entry at this trail ride shall constitute  an agreement that the person making it, and the horse, shall be subject to the constitution and rules of NEW HAMPSHIRE HORSE & TRAIL ASSOC. [NHH&TA]. It shall further constitute that every horse and rider is eligible as entered, and that the owner and his representatives are bound by the decision of the hearing committee on any questions arising under said rules, and agree to hold harmless the DTR  &   NHH&TA and their officials, directors and employees for any action taken.

 

I, my party, and my heirs, further agree  that if any damage is occasioned by, or injury or loss occur to myself or the horse entered, or to any vehicle or other article or possession that  I may send with such horse, that I will make no claims, either now or forever thereafter.  I further agree to indemnify, forever, the ride, the DERRY TRAIL  RIDERS, INC. (DTR) Ride  Committee, NHH&TA, Bear Brook State Park, State of New Hampshire and any property owners and any participants in the event against all claims, demands, suits, and loss or damage to any property or person caused by myself, my horse, my attendants or my vehicle.

 

The undersigned acknowledges and fully understands that each participant will be engaging in activities that involve risk of serious injury, including permanent disability and death and severe social and economic losses which might result  from their own actions or inactions, from the actions or inactions of others,  or from other risks not known to us or reasonably foreseeable at this time.  Said undersigned  assumes all the foregoing risks and accepts personal responsibility for the damages following such injury, permanent disability or death. Said undersigned has read and signed this Waiver and Release voluntarily and understands that he or she has given up substantial rights.

 

I understand that trail riding can involve being in remote areas for extended periods of time, far from communications, transportation, and medical facilities;   and that these areas may have many natural hazards which ride management cannot anticipate, identify, modify, or eliminate; that horses can be excitable, difficult to control,  and unpredictable; and that accidents can happen to anyone at any time.

 

Signature of Rider ____________________________________________ Date____________

 

FOR MINORS signature of parent or guardian__________________________________

 

MEDICAL WAIVERS AND INFORMATION

   FOR MINORS

 

In case of injury to a minor, this authorizes DERRY TRAIL RIDERS, INC., or its agents to secure whatever emergency medical treatment is needed for my minor child entered in this event, with no liability whatsoever to DTR,   the owners of the properties, or anyone involved in this ride.

 

Signature of Parent/Guardian for minor child______________________________________

 

Phone number where parent or guardian may be reached____________________________

 

   FOR ALL RIDERS

 

List Allergies                           _________________________________________________

 

Other Pertinent Information_________________________________________________

 

Regular Doctor & Phone___________________________________________________

 

Insurance Carrier_________________________________________________________

 

Name and Phone of nearest relative__________________________________________

 

If you desire to give it, this information could be of help in an emergency.

 

Return form together with fees to:  Pat Darmofal, 12 Kelly St., Haverhill, MA  01832

Or e-mail to patdarmofal@msn.com OR CALL 978-372-1986

 

DEADLINE FOR MEAL RESERVATIONS IS May 16, 2008

Please make checks payable to DERRY TRAIL RIDERS. INC.

PAID IN FULL PRE-REGISTRATIONS GET A FREE GAS CARD RAFFLE TICKET