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Release and Hold Harmless Agreement

WHEREAS, the UNDERSIGNED acknowledges the inherent risks involved in riding and working around horses, which risks include bodily injury from using, riding or being in close proximity to horses, among other risks, and further, that both horse and rider can be injured in normal use or in competition and schooling;

I understand that it is my responsibility to wear the appropriate equestrian equipment, as well as protective equipment, included by not limited to helmet and boots;

IN CONSIDERATION, therefore, for the privilege of taking riding lessons and/or working around horses at Flintrock Stables, located at 16 East Brubaker Valley Road, Lititz, PA 17543, the Undersigned does hereby agree to hold harmless and indemnify Flintrock Stables LLC, Flintrock Corporation, Flintrock Farms, Daniel Heller, Jennifer Heller, and all associates of Flintrock, and further release them from any liability or responsibility for accident, damage, injury, or illness to the undersigned or any horse owned by the undersigned or any family member or spectator accompanying the Undersigned.

I also hearby grant Flintrock Stables permission to use my and/or my child’s photo and name for the purpose of promotional material, website, and/or social media content.

Date: April 8, 2026

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant's Information
Family Physician:
Physician Address:
Physician Phone:
Hospital Preference:
List any allergies child may have:
Contact Me Immediately at this phone number:
If unable to contact me please call:
And/or this person:
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Family Physician:
Physician Address:
Physician Phone:
Hospital Preference:
List any allergies child may have:
Contact Me Immediately at this phone number:
If unable to contact me please call:
And/or this person:
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Family Physician:
Physician Address:
Physician Phone:
Hospital Preference:
List any allergies child may have:
Contact Me Immediately at this phone number:
If unable to contact me please call:
And/or this person:
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Family Physician:
Physician Address:
Physician Phone:
Hospital Preference:
List any allergies child may have:
Contact Me Immediately at this phone number:
If unable to contact me please call:
And/or this person:
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Family Physician:
Physician Address:
Physician Phone:
Hospital Preference:
List any allergies child may have:
Contact Me Immediately at this phone number:
If unable to contact me please call:
And/or this person:
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Family Physician:
Physician Address:
Physician Phone:
Hospital Preference:
List any allergies child may have:
Contact Me Immediately at this phone number:
If unable to contact me please call:
And/or this person:
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Family Physician:
Physician Address:
Physician Phone:
Hospital Preference:
List any allergies child may have:
Contact Me Immediately at this phone number:
If unable to contact me please call:
And/or this person:
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Family Physician:
Physician Address:
Physician Phone:
Hospital Preference:
List any allergies child may have:
Contact Me Immediately at this phone number:
If unable to contact me please call:
And/or this person:
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Family Physician:
Physician Address:
Physician Phone:
Hospital Preference:
List any allergies child may have:
Contact Me Immediately at this phone number:
If unable to contact me please call:
And/or this person:
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Family Physician:
Physician Address:
Physician Phone:
Hospital Preference:
List any allergies child may have:
Contact Me Immediately at this phone number:
If unable to contact me please call:
And/or this person:
Parent or Guardian's Email Address
Email*
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Participant's 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(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.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Information
Family Physician:
Physician Address:
Physician Phone:
Hospital Preference:
List any allergies child may have:
Contact Me Immediately at this phone number:
If unable to contact me please call:
And/or this person:
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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