Summer Camp 2023 Week 6 Registration TBD Release for *MUST* be filled out for each camperONE submission per camper is good for all summer camp weeks and/or volunteer hours. Standard Release To include: Activities held at 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: * StudentStaff Boarder4-H MemberVolunteerCommunity Service HoursOther Other Relationship * 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 Participant Name * Date of Birth * Age Height * Weight * -50 51 – 100 101 – 150 151 – 175 176 – 200 200+ (Riders over 200lbs will be evaluated on an individual basis) Current Riding Experience: If participant is under 18, name of parent or legal Guardian: * Father Mother Guardian Name * Name of your spouse/second parent (if applicable): 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 Home Phone Work Phone Cell Phone 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. 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 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 Signature Clear Signature of student, parent, guardian or volunteer (must be 18 years of age to sign for yourself) Date of Release Addendum to Liability Release – COVID-19 The undersigned, being of legal age or signing in conjunction with a parent or legal guardian, understands and agrees that, due to the COVID-19 (coronavirus) pandemic, that I, and any parent or legal guardian or other person who appears with me, come to Line it Up, LLC, voluntarily and will follow the recommendations of the Center of Disease Control “CDC” and the Governor of PA. I/We shall wear a mask whenever I/we are inside the barn facility at Line it Up, LLC and when social distancing is not a viable option. I/we shall follow guidelines of social distancing, hand washing and hand sanitizing (as per the recommendation of the Center for Disease Control (“CDC”)) while at Line it Up, LLC and/or facilities owned or controlled by Line it Up, LLC. I/we shall use hand sanitizer and/or wash our hands right before entering inside the barn facility of Line it Up, LLC. I/we agree to follow any and all posted signage regarding safety and COVID-19 at Line it Up,LLC. I/We acknowledge the restrictions and recommendations set forth by the governor of PA and the CDC and, I/we choose to continue to participate in equine activities held at Line it Up, LLC, use their facilities, horses and/or to receive training or instruction from the agents or employees of Line it Up, LLC. I/We are fully aware of the risk of injury and dangers inherent in the riding and handling of horses, I am fully aware of the risks of COVID-19, and, hereby elects voluntarily to participate in said activities, and do hereby willingly enter into this Addendum to Release, Waiver & Indemnity Agreement. In the event I/we become infected with COVID-19, or experience symptoms consistent with any symptoms of COVID-19, I/we agree that I/we will notify an owner of Line it Up, LLC, immediately, and will not come to Line it Up, LLC and/or any facilities either owned or controlled by Line it Up, LLC, until an appropriate quarantine period has passed, or I/we have received a negative COVID-19 test. I/we specifically agree to waive my/our rights to sue Line it Up, LLC or any of its owners, officers, directors, shareholders, employees, agents, lessors, successors, heirs, and assigns, for any injury, death, loss, or damage caused to me/us and I/we agree to assume all risks inherent in engaging in the activities at Line it Up, LLC during the COVID-19 pandemic. In addition, I/we agree to indemnify, defend and hold harmless Line it Up, LLC, their owners, officers, directors, shareholders, employees, agents, successors, heirs, and assigns from any loss, claim, suit, or judgment resulting from any injury, death, loss or damage sustained or claimed by rider (or rider’s personal representative) as a result of the COVID-19 virus and pandemic, and further to indemnify Line it Up, LLC, their owners, officers, directors, shareholders, employees, agents, successors, heirs, and assigns from any and all costs of defending such claims, including attorneys’ fees. CAUTION: READ BEFORE SIGNING (PARENT OR GUARDIAN MUST SIGN IN ADDITION TO RIDER UNDER EIGHTEEN YEARS OF AGE) Rider’s Signature (Unless rider is under 13) Clear Signature of Parent or Guardian Clear Date or Release Rider’s Name Printed Parent or Guardian Name Printed Address Phone Email Paragraph If you are human, leave this field blank. Submit Release
