Pony Club Winter Session

Pony Club Winter Registration

January 4th-February 13th (6 weeks) $405
Please select the days you are available: *

Monday Tuesday Wednesday Thursday Friday Saturday (MORNING ONLY)
Student Information
Student's Name *

First Name Last Name
Birth Date *

Month Day Year
Grade
Gender

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Information
Name *

First Name Last Name
Cell Number *
E-mail *
example@example.com
Emergency Information
Emergency Contact's Name *

First Name Last Name
Relationship *
Phone Number *
Alt. Phone Number
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the student prescribed an inhaler? If yes, please explain any instructions.
Should be Empty:

Pony Club Winter Registration