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: ____________________________________________________