Summer Camp Registration Form
These forms are required for your children to attend camp.
Camper's Information
Member ID
Camper Name
*
Nickname
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Age
Entering Grade in 2022/23
*
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Other
Previous Experience with Horses?
Yes
No
If yes, please describe experience
Summer Camp Week/Session Attending
Week 1 : June 13 - 17
Week 2 : June 20 - 24
Week 3 : July 11 - 15
Week 4 : July 18- 22
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Parents' Information
Parent/Guardian 1
Parent/Guardian 1
*
First Name
Last Name
Relationship to Child
*
E-mail
*
Cell Phone
*
Home Phone
Home Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Parent's Work
*
Or enter N/A if not applicable
Parent's Work
Where would you like to be reached while your child is at camp?
*
Cell Phone
Work Phone
Home Phone
Parents' Information
Parent/Guardian 2
Parent/Guardian 2
*
First Name
Last Name
Relationship to Child
*
E-mail
*
Cell Phone
*
Home Phone
Home Address Same as Parent/Guardian 1?
Yes
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent's Work
*
Or enter N/A if not applicable
Parent's Work
*
Where would parent/guardian 2 like to be reached while your child is at camp?
Cell Phone
Work Phone
Home Phone
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Emergency Contacts/Authorized Pickup
Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within 40 minutes from the barn, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. All campers are released at the end of their camp to their parent/guardian or one of the individuals listed on this form. Photo ID must be provided at the time of pick up. NO EXCEPTIONS!
Emergency Contact #1
Full Name
*
First Name
Last Name
Primary Phone Number
*
Relationship to Camper
*
Emergency Contact #2
Full Name
First Name
Last Name
Primary Phone Number
Relationship to Camper
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Medical / Health Information
Name of Physician or Clinic/Hospital
Phone Number
-
Does your child have any food, medication or environmental allergies?
*
Yes
No
Allergies? Check all that apply
*
Food
Medication
Environmental
Please provide a detailed description of any medical/allergies/physical conditions we should be aware of, regarding your child's health or personality that will help us make the camp experience more enjoyable!
*
0/150
List any history of hospitalization, outpatient surgery, or previous health concerns that would be needed to assist the staff or medical personnel in an emergency situation.
*
0/200
...Now that we know about your child...let's talk about the legal stuff...
Authorization for Treatment: I hereby give permission to the medical personnel selected by the camp director to order treatment and necessary transportation for my child. In the event I cannot be reached in an emergency. I hereby give my permission to the physician to secure and administer treatment, including authorization for my child named above. PLEASE INITIAL BELOW
*
0/150
Photo Release: I hereby give permission for my child's picture taken during the summer camp to be used by Horse Club Miami for promotional purposes. PLEASE INITIAL BELOW
*
0/150
I understand that Covid19 safety measures require that my child’s temperature will be taken every morning at arrival time and that I cannot leave the premises until his/her temperature has been cleared. PLEASE INITIAL BELOW
*
0/150
I certify that my child has not been coughing or have had shortness of breath in the past 14 days and has not traveled abroad during the last 14 days. PLEASE INITIAL BELOW
*
0/150
Outdoor Activities: I understand that the camp at Horse Club Miami includes outdoor activities. I give my permission for my child to participate in all water activities included in the camp. PLEASE INITIAL BELOW
*
0/150
NOTE: BY INITIALING ABOVE, I ACKNOWLEDGE THAT YOU HAVE READ AND AGREED TO EACH ITEM.
Signature
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Payment and Statement of Understanding
SUMMER CAMP SESSIONS AVAILABLE
Week 1 - $475 (June 13 - 17)
Week 2 - $475 (June 20 - 24)
Week 3 - $475 (July 11 - 15)
Week 4 - $475 (July 18 -22)
Non-Refundable deposit to reserve my child's spot per week - $150
Credit Card Information
*
First Name
Last Name
*
Credit Card Number
Security Code
*
Expiration Date
Zip Code
This form, after being completed and signed by the parent/guardian, must be reviewed for completeness and signed by Horse Club Miami prior to the child receiving care. The parent/ guardian and the administrator or designee shall initial and date the form in the section below to indicate when the form was last reviewed.
*
Type first and last name above to consent
*Please scroll through the entire Statement of Understanding before clicking the box*
Sign Document
*
Date Signed
*
-
Month
-
Day
Year
Date Picker Icon
Camp Director Name and Contact Info
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SUBMIT
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