Summer Camp Detailed Registration Form

Camper's Information

Camper's Name

First Name Last Name

Birth Date

Month Day Year

Grade

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

Which camp are you interested in?

Full day camp (June 26-29) $485 ( non refundable deposit $200)Half day camp (July 17-19th) $350 (non refundable deposit $100)Half day Camp (July 31-Aug 2) $350OFF PREMISES OVERNIGHT CAMPING WITH HORSES Aug 11-13 or Aug 18-20Junior Trainer Camp (June 12- 15) $485 (nonrefundable deposit $200)OTHER

If you have other dates needed for camp and have at least 3 individuals interested please state the desired type of camp and dates below. IE Women's camp, another full day camp, etc.

Would you like to bring your own horse to camp?

Does Camper have experience with horses? Please let us know if they have attended camps, own a horse, or attend lessons.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Pine Lake Pastures, Hereby known as PLP during the selected camp. In exchange for the acceptance of said child’s candidacy by PLP, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless PLP, Terry/Carol McKinley, all Owners of horses at PLP, volunteers and trainers 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 PLP. 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 horseback riding. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, concussions or death.

Medical Release and Authorization

As Parent and/or Guardian of the named camper, 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.

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.

Date

Signature

Clear

Once form is submitted, Pine Lake Pastures will respond either by email or text to confirm camper's spot and request deposit. A letter regarding camp will be emailed to the above email address to confirm and let you know all the information regarding camp. THANK YOU!

Summer Camp Registration