Customer Information Form If multiple owners, please fill out separate forms for each owner. Owner's Name* First Last Owners Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Enter Email Confirm Email Cell Phone*Home Phone*Work Phone*Emergency Contact 1* First Last Emergency Contact 1 Phone*Emergency Contact 2* First Last Emergency Contact 2 Phone*If We Cannot Reach YouI give my consent for Summer Wind Farm to seek and/or provide/administer medical care, and make decisions for my horse(s) well being in my absence. I understand I will be responsible for all expenses related to the care of my horse(s). Understanding that Summer Wind Farm (Robert J. LaPorta, employees) shall exercise good judgment and reasonable care, I hold harmless and release Summer Wind Farm (Robert J. LaPorta / employees) from all liability or responsibility for the outcome of sickness, injury, or other accidental damage.Date* Date Format: MM slash DD slash YYYY Signature* Share this:TweetPrint
