Line It Up Standard Riding Release To include: Activities held at or by Line It Up, LLC, or for Windy Hollow Farm, Windy Hollow Farm 4H, and Pony Partners. My relationship with Line it Up, LLC is as a: * StudentStaffBoarderVolunteerCommunity Service Hours4-H MemberOther My relationship with Line it Up, LLC is as a: Other Relationship Student/Participant Name * Student/Participant Name First First Last Last Parent/Guardian Name (or N/a if over 18) * Parent/Guardian Name (or N/a if over 18) First First Last Last Relation to Student Mother Father Guardian Student/Participant Date of Birth * Student/Participant Age Student/Participant Height * Student/Participant Weight * -50 51 – 100 101 – 150 151 – 175 176 – 200 200+ (Riders over 200lbs will be evaluated on an individual basis) Current Riding Experience: Participants Address * Participants Address Participants Address Participants Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Best Phone Number * Secondary Phone Number Email * Confirm Email * Please enter the same email address to confirm. Party responsible for payment of lessons or activities held at Line it Up, LLC if other than above persons: Name * Email * Best Phone # * Responsible Party Address * Responsible Party Address Responsible Party Address Responsible Party Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal In case of an emergency, for participants under 18 parent/guardian will be called first: Contact Name * Emergency Phone 1 * Emergency Phone 2 (if necessary) LIABILITY RELEASE In consideration of accepting (participant’s name) in the riding/educational programs, or any other activities held at Line it Up Farm, Windy Hollow Farm, with Windy Hollow 4-H or Pony Partners, I understand that horses are unpredictable by nature and I voluntarily assume the risks and dangers involved. I hereby, intending to be legally bound, for myself or my minor child, my heirs, executors or administrators, waive and release all claims for damages I may have against Line it Up, LLC, Windy Hollow Farm, or Pony Partners, its Owners, Instructors, Volunteers, Aides and or Employees for any and all injuries and or loses. A non-employee is not covered by Line it Up’s, Windy Hollow Farm, or Pony Partners, insurance or worker’s compensation policy. Respecting the ability of the horses owned and used by Line it Up, Windy Hollow Farm or Pony Partners, riders who are over 200 pounds will be evaluated on an individual basis. Line it Up, LLC, Windy Hollow Farm, Windy Hollow 4-H, and Pony Partners, are not responsible for loss or damage of any personal items ie: helmets, cell phones, etc. MEDICAL RELEASE The above student hereby (check one) * Consents Does not consent to any medical, dental, or surgical treatment or procedure of an emergency nature that is reasonably necessary to save the life of the person named above or to restore the person to health. I understand that should medical emergency treatment be required, the current insurance information listed here will be provided to the attending clinic or hospital to cover future payment of incurred bills. HELMET REQUIREMENT & SUGGESTED RIDING ATTIRE An ASTM-SEI approved helmet is recommended for all Line it Up, LLC participants while mounted and is required while mounted by all riders under the age of 18 and ALL AGE riders on lesson horses. I have been advised to wear hard soled shoes and pants in and around the stables and while working with or riding horses, to help prevent horse related injuries. (Open toe shoes are not allowed in the stable area). Helmet Consent I understand the helmet policy and as an adult opt to ride without a helmet. DOES NOT APPLY TO ADULTS RIDING LESSON HORSES INSURANCE The above-named student carries accident/medical insurance: * Yes No Name of Insurance * Policy # * PHOTO/SOCIAL MEDIA RELEASE The above-named student or their parent or Guardian hereby * Authorizes Does Not Authorize Line it Up, LLC, Windy Hollow Farm, Windy Hollow 4-H or Pony Partners the use and reproduce all photographs taken for promotional and or printed materials. POLICY OF CONFIDENTIALITY All information including but not limited to, personal, medical, and financial documents are confidential among all participants, volunteers, and staff. Confidentiality is considered one of our most basic responsibilities. ACCEPTANCE OF POLICIES I have read, understand and will respect Line it Up, LLC, Windy Hollow Farm, Windy Hollow 4-H, and Pony Partners, policies as they pertain to: The Release of Liability, Photo/Social Media Release and Policy of Confidentiality, and Helmet Policy. Signature * signature keyboard Clear Signature of student, parent, guardian or volunteer (must be 18 years of age to sign for yourself) Date of Release Community Service and Volunteers only Please check the appropriate box(s). Volunteers/employees 18 years and or older MUST have proof of a current/clear Pennsylvania Child Abuse History Clearance (this is a State Law) before they can attend Volunteer Training. Those doing service/school or community service hours are responsible for keeping a copy of their hours when they leave, Line it Up, LLC will not keep track of your hours. Copy of Child Abuse History Clearance and Criminal Background Clearance are attached (Clearances must dated within the last 3 years) I acknowledge that I am responsible for keeping track of my volunteer or service hours. Clearance Files Drop a file here or click to upload Choose File Maximum file size: 516MB reCAPTCHA Submit Release