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Liability Wavier

I (we) authorize Landon Farm, it's agents and employees, to provide emergency health care services in an emergency situation, and further authorize Landon Farms, it's agents and employees, to transport my (our) child/self to emergency health care facilities for emergency treatment-further authorization is granted for other travel of a recreational nature, and I (we) expressly release from liability Landon Farm, it's agents and employees, for any damages or injuries sustained by my (our) child/self as result of said travel or said emergency health care service.

Warning - Under North Carolina law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in equine activities resulting exclusively from the inherent risks of equine activities.  Chapter 99E of the North Carolina General Statutes.

The undersigned parents and/or legal guardians of Minor, herein after referred to as student, do hereby forever release Landon Farm, their agents and employees, and their heirs, successors and assigns, from liability for any damages or injuries of whatever nature and however caused which may be sustained by student during student's participation on horse riding lessons at Landon Farm facilities.  This release from liability specifically includes, but not limited to, damages and injuries caused by horse bites, kicks, bucks, falls and collisions, as well as damages and injuries not related to horses, and associated activity on or about the premises before and after the actual lesson itself.

Photograph & Video Release Form

I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or video tape without payment or any other consideration.  I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording.  I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.  

Photographic, audio or video recordings may be used for the following purposes:

  • conference presentations
  • educational presentations or courses
  • informational presentations
  • on-line marketing
  • educational and marketing videos

By signing this release, I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in the public setting.

I will be consulted about the use of the photographs or video recording for any purpose other than those listed above.

There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.

This release applies to photographic, audio or video recordings collected as part of the sessions listed on this document only.

By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational and marketing purposes.

Today's Date: October 30, 2020

First Riders Name

First Name*

Middle Name

Last Name*

Phone*
First Riders Date of Birth*
First Riders Information
Any special instructions on health of rider?*
No
Yes

If you answered yes to this or the question, below - do not allow your ridder to interact with any of our animals until we can discuss and ensure we have plan that will be mutually agreed upon to your rider and our trainer. Safety is the most important thing we do.


Any special medications? *
Has the rider or anyone in the home of the rider been diagnosed with, exposed to, or exhibited any symptoms of COVID-19, also known as the novel Corona virus?*
No
Yes
Does the rider have a fever or other signs of ill health such as problems breathing, coughing, trouble maintaining balance, etc?*
No
Yes
First Riders Signature*
Second Riders Name

First Name*

Middle Name

Last Name*

Phone*
Second Riders Date of Birth*
Second Riders Information
Any special instructions on health of rider?*
No
Yes

If you answered yes to this or the question, below - do not allow your ridder to interact with any of our animals until we can discuss and ensure we have plan that will be mutually agreed upon to your rider and our trainer. Safety is the most important thing we do.


Any special medications? *
Has the rider or anyone in the home of the rider been diagnosed with, exposed to, or exhibited any symptoms of COVID-19, also known as the novel Corona virus?*
No
Yes
Does the rider have a fever or other signs of ill health such as problems breathing, coughing, trouble maintaining balance, etc?*
No
Yes
Second Riders Signature*
Third Riders Name

First Name*

Middle Name

Last Name*

Phone*
Third Riders Date of Birth*
Third Riders Information
Any special instructions on health of rider?*
No
Yes

If you answered yes to this or the question, below - do not allow your ridder to interact with any of our animals until we can discuss and ensure we have plan that will be mutually agreed upon to your rider and our trainer. Safety is the most important thing we do.


Any special medications? *
Has the rider or anyone in the home of the rider been diagnosed with, exposed to, or exhibited any symptoms of COVID-19, also known as the novel Corona virus?*
No
Yes
Does the rider have a fever or other signs of ill health such as problems breathing, coughing, trouble maintaining balance, etc?*
No
Yes
Third Riders Signature*
Fourth Riders Name

First Name*

Middle Name

Last Name*

Phone*
Fourth Riders Date of Birth*
Fourth Riders Information
Any special instructions on health of rider?*
No
Yes

If you answered yes to this or the question, below - do not allow your ridder to interact with any of our animals until we can discuss and ensure we have plan that will be mutually agreed upon to your rider and our trainer. Safety is the most important thing we do.


Any special medications? *
Has the rider or anyone in the home of the rider been diagnosed with, exposed to, or exhibited any symptoms of COVID-19, also known as the novel Corona virus?*
No
Yes
Does the rider have a fever or other signs of ill health such as problems breathing, coughing, trouble maintaining balance, etc?*
No
Yes
Fourth Riders Signature*
Fifth Riders Name

First Name*

Middle Name

Last Name*

Phone*
Fifth Riders Date of Birth*
Fifth Riders Information
Any special instructions on health of rider?*
No
Yes

If you answered yes to this or the question, below - do not allow your ridder to interact with any of our animals until we can discuss and ensure we have plan that will be mutually agreed upon to your rider and our trainer. Safety is the most important thing we do.


Any special medications? *
Has the rider or anyone in the home of the rider been diagnosed with, exposed to, or exhibited any symptoms of COVID-19, also known as the novel Corona virus?*
No
Yes
Does the rider have a fever or other signs of ill health such as problems breathing, coughing, trouble maintaining balance, etc?*
No
Yes
Fifth Riders Signature*
Sixth Riders Name

First Name*

Middle Name

Last Name*

Phone*
Sixth Riders Date of Birth*
Sixth Riders Information
Any special instructions on health of rider?*
No
Yes

If you answered yes to this or the question, below - do not allow your ridder to interact with any of our animals until we can discuss and ensure we have plan that will be mutually agreed upon to your rider and our trainer. Safety is the most important thing we do.


Any special medications? *
Has the rider or anyone in the home of the rider been diagnosed with, exposed to, or exhibited any symptoms of COVID-19, also known as the novel Corona virus?*
No
Yes
Does the rider have a fever or other signs of ill health such as problems breathing, coughing, trouble maintaining balance, etc?*
No
Yes
Sixth Riders Signature*
Seventh Riders Name

First Name*

Middle Name

Last Name*

Phone*
Seventh Riders Date of Birth*
Seventh Riders Information
Any special instructions on health of rider?*
No
Yes

If you answered yes to this or the question, below - do not allow your ridder to interact with any of our animals until we can discuss and ensure we have plan that will be mutually agreed upon to your rider and our trainer. Safety is the most important thing we do.


Any special medications? *
Has the rider or anyone in the home of the rider been diagnosed with, exposed to, or exhibited any symptoms of COVID-19, also known as the novel Corona virus?*
No
Yes
Does the rider have a fever or other signs of ill health such as problems breathing, coughing, trouble maintaining balance, etc?*
No
Yes
Seventh Riders Signature*
Eighth Riders Name

First Name*

Middle Name

Last Name*

Phone*
Eighth Riders Date of Birth*
Eighth Riders Information
Any special instructions on health of rider?*
No
Yes

If you answered yes to this or the question, below - do not allow your ridder to interact with any of our animals until we can discuss and ensure we have plan that will be mutually agreed upon to your rider and our trainer. Safety is the most important thing we do.


Any special medications? *
Has the rider or anyone in the home of the rider been diagnosed with, exposed to, or exhibited any symptoms of COVID-19, also known as the novel Corona virus?*
No
Yes
Does the rider have a fever or other signs of ill health such as problems breathing, coughing, trouble maintaining balance, etc?*
No
Yes
Eighth Riders Signature*
Ninth Riders Name

First Name*

Middle Name

Last Name*

Phone*
Ninth Riders Date of Birth*
Ninth Riders Information
Any special instructions on health of rider?*
No
Yes

If you answered yes to this or the question, below - do not allow your ridder to interact with any of our animals until we can discuss and ensure we have plan that will be mutually agreed upon to your rider and our trainer. Safety is the most important thing we do.


Any special medications? *
Has the rider or anyone in the home of the rider been diagnosed with, exposed to, or exhibited any symptoms of COVID-19, also known as the novel Corona virus?*
No
Yes
Does the rider have a fever or other signs of ill health such as problems breathing, coughing, trouble maintaining balance, etc?*
No
Yes
Ninth Riders Signature*
Tenth Riders Name

First Name*

Middle Name

Last Name*

Phone*
Tenth Riders Date of Birth*
Tenth Riders Information
Any special instructions on health of rider?*
No
Yes

If you answered yes to this or the question, below - do not allow your ridder to interact with any of our animals until we can discuss and ensure we have plan that will be mutually agreed upon to your rider and our trainer. Safety is the most important thing we do.


Any special medications? *
Has the rider or anyone in the home of the rider been diagnosed with, exposed to, or exhibited any symptoms of COVID-19, also known as the novel Corona virus?*
No
Yes
Does the rider have a fever or other signs of ill health such as problems breathing, coughing, trouble maintaining balance, etc?*
No
Yes
Tenth Riders Signature*
Riders Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Any special instructions on health of rider?*
No
Yes

If you answered yes to this or the question, below - do not allow your ridder to interact with any of our animals until we can discuss and ensure we have plan that will be mutually agreed upon to your rider and our trainer. Safety is the most important thing we do.


Any special medications? *
Has the rider or anyone in the home of the rider been diagnosed with, exposed to, or exhibited any symptoms of COVID-19, also known as the novel Corona virus?*
No
Yes
Does the rider have a fever or other signs of ill health such as problems breathing, coughing, trouble maintaining balance, etc?*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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