Contact Us Send A Message Name First Last Email Comment or MessageCAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms. Address 12 Ballylagan Road,Straid, Ballyclare,Co. Antrim, BT39 9NF Contact Us Phone 07926 622 351 Contact Us Email firstname.lastname@example.org RIDER REGISTRATION FORM STRICTLY CONFIDENTIAL PLEASE COMPLETE ALL SECTIONS & BOXES Step 1 of 3 33% Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone*Email* Date of Birth* Date Format: DD slash MM slash YYYY Age*Weight*Height*Occupation* Have you (or the person you are signing for) ever suffered a serious injury or discomfort while riding or been advised not to ride?* Yes No PLEASE DETAIL ANY DISABILITY OR MEDICAL CONDITIONS THAT MAY AFFECT YOUR ABILITY TO RIDE OR WHICH YOUR INSTRUCTOR SHOULD BE AWARE OF IN CASE OF AN EMERGENCY. OR TYPE NONE.*EMERGENCY CONTACT & DOCTOR’S DETAILSContact Name*Doctor*Relationship*Surgery / Town*Telephone*Mobile* RIDING ABILITY - YOU MUST TICK ALL BOXES THAT APPLYI consider myself (or the person riding for whom I am signing on behalf as a minor) to be a:* Never Ridden Before Beginner Novice Internediate Advanced How many times have you/rider ridden in the last 12 months* None Under 12 12-40 40+ What do you believe your or the person riding’s capabilities on a horse or pony to be:* Select All Riding at a walk Trotting with Stirrups Trotting without Stirrups Cantering Hacking Riding over jumps up to 0.5m (I8”) Riding over jumps up to 0.75m (30”) Riding over cross country jumps (30”+) RIDERS UNDER 16 YRS OF AGE: I accept full responsibility for my child and confirm that the above pre-assessed abilities are correct. I accept my child rides at his/her own riskRIDERS AGED 16 YRS & OVER: I confirm that the above pre-assessed abilities are correct and I agree that I RIDE ENTIRELY AT MY OWN RISK. DATA PROTECTION ACT 1998: I understand that the information I have given will be held In accordance with the Data Protection Act 1998 but may also be made available to insurers and other concerned parties in the event of any injury or accident. I understand that I must obey the instructions of the instructor and must comply with the Health & Safety requirements of the establishments. I confirm that to the best of my knowledge all the above details are correct. A parent or guardian of riders under the age of I6 must sign this form. I acknowledge that RIDING IS A RISK SPORT AND HOLDS A POTENTIAL DANGER, and that all horses may react unpredictably on occasions.Tick this box to give permission to be photographed for advertising and social media purposes* Yes No Print Name*Date* Date Format: MM slash DD slash YYYY Signature*RELATIONSHIP (IF SIGNING ON BEHALF OF RIDER): OR TYPE NONE.*CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.