FISHER RANCH
8101 Oakenshield Lane, Pass Christian, MS 39571
(228)452-7055 or (228)669-0502
REGISTRATION FORM AND ACCIDENT WAIVER
DATE:________________PHONE NUMBER:_______________________________
STUDENT'S NAME:____________________________________________________
ADDRESS:_____________________________________________________________
CITY:______________________________ STATE:_______ ZIP:________________
AGE:______ DATE OF BIRTH:____________________
T-SHIRT SIZE: YS YM YL AS AM AL AXL AXXL
MOTHER'S NAME AND PHONE:________________________________________
FATHER'S NAME AND PHONE:_________________________________________
EMERGENCY CONTACTS AND PHONE NUMBERS:
RIDING EXPERIENCE:_________________________________________________
PLEASE LIST MEDICAL CONDITIONS AND OTHER CONCERNS:
DOCTOR'S NAME AND PHONE NUMBER:
AGREEMENT TO RELEASE AND WAIVER OF LIABILITY
I fully understand that horse riding, handling, and grooming of horses and other ranch activities can be
dangerous. All animals are unpredictable, and while Fisher Ranch exercises care in the selection,
training, and use of its horses, it is impossible to guarantee the behavior or actions of the horse at all
times, or in all situations. I wish to participate or allow my child to participate in these activities knowing
that horses and ranch activities can be dangerous. I accept and assume all the risks injury (including
death) to my child or myself or my property. I represent and warrant that I have the legal authority to
give this release. In exchange for my child or myself being permitted to participate in these activities for
my child, myself, and my child's heirs, guardians and legal representatives, I release and agree not to
make or bring any claim of any kind against Fisher Ranch or its owners, directors or employees for any
injury (including death), to my child or myself or any damage to my property whether from anyone's
negligence or not or any other cause, arising out of my child's or my participation in horseback riding or
related activities or all other camp activities; I also agree that if anyone makes any claims because of any
injury to my child or myself (including death), or for any damage to my property, I will keep all those
released by this agreement free of any damages of costs because of those claims. The undersigned hereby
certifies that they are the legal parent or guardian of the child and that they desire the child to participate
in the full program of all activities, unless they provide other advice in writing. Further, that if the
registrant should become ill or suffer an accident requiring medical attention Directors of Fisher Ranch
are granted full permission to take whatever action they may deem necessary or advisable, and to
authorize appropriate medical treatment, recognizing that every reasonable effort will be made to contact
the parent or guardian. The undersigned agrees to be responsible for any and all expenses incurred. The
parent or guardian (if registrant is under the age of 18) or registrant must sign this form in order to be
registered. I hereby certify that I have read, understood, and agree to abide by the conditions and
agreement outlined above.
I also understand that pictures and videos may be taken to publish in various media. I grant these media
the irrevocable and unrestricted right to use and publish photographs and video of camp participant
without restriction and without inspection or approval. I hereby release the Fisher Ranch, owners,
employees, photographer and legal representatives and assigns from all claims and liability relating to
said photographs and video.
WARNING
Under Mississippi law, an equine activity or equine sponsor is not liable for an injury or to the death of a
participant in equine activities resulting from the inherent risks of equine activities, pursuant to this
chapter. Chapter 11 Section 95-11-1, 95-11-5, 95-11-7
Date:___________________ Student's Name (PRINT):____________________________________
Student's Signature:__________________________________________
Parent or Guardian Name (PRINT):__________________________________________________
Parent or Guardian Signature:________________________________________________________
****THIS FORM MUST BE NOTARIZED****
Sworn and subscribed to me this the _____ day of _______________ in the year __________.
Signature of notary:________________________________________________
