Rider’s Name ____________________________ VHSA Member # __________     Adult     Junior     (Circle one)

Classes Entered _________________________________________ Total # of classes ________ X $12**= ______

Check # ______________   Amount ______________

Owner’s Name (if different from Rider) ____________________________________

Address __________________________________________ City __________________ State ___ Zip ________

Rider’s Name ____________________________________

Address __________________________________________ City __________________ State ___ Zip ________

Trainer’s Name ____________________________________

Where stabled __________________________________________________

The Virginia State Equine Activity Act of 1991 requires equine activity sponsors to notify all equine activity participants of the risks inherent in equine activities, and requires all participants to agree to assume all risks specifically enumerated in order for the conditions of the Act to be met. Oak Hill Thoroughbreds L.L.C. & Equestrian Center requires all boarders and other users of the equine facilities at Oak Hill Thoroughbreds L.L.C. & Equestrian Center to sign this waiver. The specific risks include the following: 1. The propensity of an equine to behave in dangerous ways which may result in injury to the participant. 2. The inability to predict an equine’s reaction to sound, movements, objects, persons or animals. 3. Hazards of surface or subsurface conditions. Please sign below indicating that you agree to assume the risks enumerated above.