Enrollment Application

I understand that this application may be accepted or rejected without notice or explanation.

Applications hereby made for the undersigned on the terms below :

Name:
__________________________________________________________________

(Please print) Last

First

Middle

Address:
__________________________________________________________________

__________________________________________________________________

E-mail Address: ____________________________________________________

Telephone:____________________	Date of Birth:___________________
Place of Birth:_________________	U.S. Citizen:____________________

Age:____

Height:____

Weight:____

Sex:____

Physical Defects:________

*Tetanus shot required*

In case of emergency, notify:

Name:__________________________	Telephone:__________________
Address:________________________________________________________

Social Security #:_____-___-_____

Signature:_______________________

Education	Level Completed	Name & Address Of School	Field Of Study
High School
Trade School
College
Military: Branch of Service______________ Years Served____________

List all experiences with horses:__________________________________ ________________________________________________________________ ________________________________________________________________

Employers or References
Name:_______________________	Phone #:______________________
Name:_______________________	Phone #:______________________
Name:_______________________	Phone #:______________________

Enrollment fee of $400.00 with this application is non-refundable if accepted into this training program.
Tuition, paid in full, is required 30 days prior to course starting date and is non-refundable. Certain circumstances may be taken into consideration.
I affirm that all information in this application is true to the best of my knowledge.

Signature:__________________________

Waiver and Release
Pennsylvania Institute for Horseshoeing (P.I.H.)

I understand that there are inherent dangers in horseshoeing and that it is a condition of my acceptance in this horseshoeing program that I assume all of the risks. I will assume and accept all responsibility for any accidents or injury which I may suffer during the time of enrollment, as well as any compensation time. I further release and discharge P.I.H., its owners, instructors, horse owners, land owners in which any instructing is taking place, bystanders or observers in or on premises in all suits, actions, and all causes of act: under the terms herein set forth.

Signature of applicant:_________________________________________

Date:______________________________________________________

Signature of parent:___________________________________________
(if applicable)

** Please make all checks payable to Glace Rider **