Payment : Cash / Check Name of Horse __________________

WAIVER AND RELEASE

WARNING: UNDER IOWA LAW, AN EQUINE ACTIVITY SPONSOR OR EQUINE PROFESSIONAL IS NOT LIABLE FOR AN INJURY TO, OR DEATH OF, A PARTICIPANT IN EQUINE ACTIVITIES RESULTING FROM THE INHERENT RISKS OF EQUINE ACTIVITIES.

RELEASE AND INDEMNITY

In consideration of receiving permission to enter upon the premises of 3111 Hartford, Des Moines, Iowa 50320, from time to time, the receipt of such permission being hereby acknowledged trainer, owner, attendant, participant or any other capacity, in an equestrian activity such as showing, taking lessons, riding or using equestrian facilities in any fashion, on said premises, the receipt of such as permission being also hereby acknowledged, the undersigned hereby releases 3111 Hartford , Park Avenue Farms L.C. , Des Moines Equestrian Center L.C. and any related or affiliated company and/or their respective owners, officers, directors, agents and employees of and from all liability, claim, demands, actions and causes of action whatsoever, arising out of or related to any loss, damage or injury, including death, that may be sustained by the undersigned while in or upon the premises.

The undersigned being fully aware of the risks and hazards inherent in entering upon said premises and/or in participating in any such equestrian activity, or lessons, or jumping or riding held at said premises, hereby elects voluntarily to enter upon premises knowing present condition and knowing that said condition may become more dangerous during the time that the undersigned is upon said condition.

The undersigned hereby voluntarily assumes all risk and loss, damage or injury, including death, that may be sustained by the undersigned, or any property of the undersigned while in or upon the premises.

In the event of injury to the undersigned, ambulance service and medical or paramedical attention may be provided, if possible by one or more of the above parties. This release extends to any or all liability arising out of, or in any way connected with such provision of ambulance service and medical or paramedical attention or failure to provide therefore.

The undersigned hereby assumes the risk of loss, damage, and/or injury including death that may be sustained by the undersigned upon riding a pony or horse owned by private owner. In the event of an accident or injury to the undersigned, the owner of the privately owned horse(s) or ponies will not be held responsible. The undersigned will be riding at their own risk. This release shall be binding upon distributees, heirs, next of kin, personal representatives, executors, and administrators of the undersigned.

The signing of the foregoing release, the undersigned hereby acknowledges and represents executors and administrators of the undersigned.

In signing the foregoing release, the undersigned acknowledges and represents that he (she) has read the foregoing release, understands it and signs it voluntarily, and that he (she) is over 18 years of age and of sound mind.

Date_______________ Request for riding helmet (initial) _____ Yes _______No

Name _________________________________________ Address________________________________________________

City_____________________________________________________ State_______________________ Zip_______________

Phone (______) ________________________ Fax _______________________ E-Mail ______________________________

Emergency Contact Name___________________________________________ Phone________________________________

Age of rider if under 18 _______________________

Signature of

Signature __________________________________ Parent or Guardian ______________________________________

If under 18