Summer Camp Detailed Registration Form

Student Information

Student's Name

First Name Last Name

Student's Name

First Name Last Name

Age of student at camp blanks .

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 athlete student have any allergies, chronic illness, or medical conditions? If yes, please describe.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Pine Lake Pastures and Terry/Carol McKinley during the selected camp. In exchange for the acceptance of said child’s candidacy by Pine Lake Pastures. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Pine Lake Pastures. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Pine Lake Pastures. including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization

As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Pine Lake Pastures. and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

What level of rider is your child 1

Never Ridden Beginner rider in your Junior Rider Program intermediate rider I have my own horse and will bring it to camp I take lessons now and I can always learn some more

What level of rider is your child 2

Never Ridden Beginner rider in your Junior Rider Program intermediate rider I have my own horse and will bring it to camp I take lessons now and I can always learn some more

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature

Clear

Youth Registration Camp

Full Day Camp June 14-17 8am-4pm Day Trail Rides, Intense learning of both Western and English, classroom learning about horses and their care and tack. Current Student 5%(USE CODE E2577) discount and 5% discount for early registration prior to April 1st. (USE CODE LMQ66) CAMPS Fill Up FAST- sign up early with $200 deposit.

$ 425.00

3 DAY Half Day Camp June 28-30 8am- 12noon This camp includes morning chores, riding, and classroom learning more about horses. Great FUN and Lasting memories! CAMPS Fill Up FAST- sign up early with $200 deposit. Use Coupon code LMQ66 if you sign up prior to April 1st for early registration (5% off), and USE COUPON CODE EZJ77 if you are a current student for an additional 5% off.

$ 275.00

Youth OVERNIGHT CAMP Jul 1-4 Camping here at farm. FULL days of riding and learning. this is one of the most bonding experiences of the summer. Current Student 5%(USE CODE E2577) discount and 5% discount for early registration prior to April 1st. (USE CODE LMQ66)

$ 500.00

Half Day Camp July 26-30 noon-4pm Riding twice a day, possible water sports, arts and crafts and classroom. A fast paced camp where the students will have a blast and learn a ton! Current Student 5%(USE CODE E2577) discount and 5% discount for early registration prior to April 1st. (USE CODE LMQ66)

$ 325.00

CAMPING AWAY YOUTH HORSE CAMP Gather at the farm and pack up to travel to a location for camping and riding. We will cook, ride, play games. Current Student 5%(USE CODE E2577) discount and 5% discount for early registration prior to April 1st. (USE CODE LMQ66)

$ 650.00

Bring My horse to camp ten dollars per day to board your horse here. No coupon applies

$ 10.00

Full day Camp Aug 2-5 Are you ready to enhance your skills in English and Gaming, Do ground work, learn more about horses, do arts and crafts and swim or kayak? This is a great camp to build lasting friendships! Current students use EZJ77 for 5% discount, and if you register and put deposit down by April 1st, receive a 2nd discount of 5% USE CODE LMQ66

$ 425.00

Enter coupon

Total

$ 0.00

YOUTH Camp Registration