Waiver Form

Agreement for acceptance of risk and waiver of liability,
for a youth 17 years of age and under as of January 1st. and for an Adult Participant
A new form is required for EACH show

This Document will affect your legal rights and liabilities

Please Read Carefully

I request permission for ________________________________, (child's name if under the age of 18yrs.)

to participate in horseback riding and other equestrian related activities organized and operated by Northumberland County Riders' Horse Club at Adanac Horse Farm.

I fully understand that horseback riding, handling and grooming of horses and other stable activities are very dangerous. I wish to allow my child to participate in these activities knowing that they are dangerous.

     I also understand that while participating in this high-risk event, it is recommended that my child wear a helmet with a fixed harness while mounted.
     By not wearing proper safety headgear, I fully accept all responsibilities for my action and my child’s action.
     I also understand that while participating in this high-risk event, having knowledge of my horse kicking, I must place a red ribbon on its tail, to warn other participants to stay a distance from my horse.
     I accept and assume all risk of injury (including death) to my child or my property. I represent and warrant that I have authority to give this release.

In exchange for myself or my child being permitted to participate in these activities, for myself, my child, my child’s heirs, guardians and legal representatives, I release and agree not to make any claims of any kind against Northumberland County Riders' Horse Club or Adanac Horse Farm, land owners, officials, servants, employees, representatives, officers and directors for any injury (including death), myself or to my child or any damage to my property, arising out of my or my child’s participation in these dangerous horseback riding or related activities.

I acknowledge as parent/guardian of _________________________________, or as an adult participant that I have read and fully understand and agree to the terms and conditions stated herein and that it is binding upon my executors, heirs and assigns.

I give permission for Northumberland County Riders' Horse Club to use my / my child's photograph only for NCR Horse Club purpose (advertising, news and banquet photo page on the web site).

Please check here:_______ ( the NCR will not post names with pictures on the web site)
I give Northumberland County Riders' Horse Club permission to use my / my child's name for show results listed on the web site and/or newsletter.
Please check here:_______

Signature of Parent /Guardian: ___________________________________Date:______________





Signature of Adult Rider:_________________________________________Date:______________





Insurance Company:_______________________________________________

Policy Number: ____________________________________________________