Date of Clinic ___________________________

Name of Rider________________________________________________________________

Address_____________________________________________________________________

Home phone_______________________________ Cell phone_________________________

Email_______________________________________________________________________

Name of horse_________________________Age____________Breed__________________________

Give a brief history and your goals for this horse____________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

______________________________________________________________

RELEASE FROM LIABILITY

I agree to hold Larry and Terry Peiper and Buck N Horse Hollow harmless from and against any and all claims, actions, damages, liability and expenses in connection with loss of life, personal injury, and or damage to property. I agree that riding horses is a dangerous sport. I, by virtue of my signature below, do hear by release Larry and Terry Peiper and their insurance company of any liability from accident or injury to my person or property.

I understand that riding horses is a very dangerous sport that may result in serious injury or death. I also understand that just like wearing a seat belt that wearing a riding helmet could help prevent injury or death.

I understand that my horse needs to be up to date on vaccines and have a negative coggins test.


Rider’s Signature_______________________________________________________

In case of emergency we should contact

Name___________________________________Phone___________________________________



Mail completed form to:  Terry Peiper  Buck N Horse Hollow  6 Buck Dr. Carlisle PA 17015 
          or FMI call (717)240-0723 or email  tpeiper@aol.com