Summer Camp Detailed Registration Form

Summer Camp Registration
Date of camp

June 10-12July 8-10
Rider Information
Rider’s Name

First NameLast Name
Birth Date

MonthDayYear
Grade
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

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

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
Does the rider have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the rider prescribed an inhaler? If yes, please explain any instructions.
Payment for camp is $225. You may pay in full or place a $50 non-refundable deposit to secure your spot. If you chose to place a deposit, The remaining balance must be paid 30 days prior to the camp date. Balance due for the June camp will be May 12th. Balance due for the July camp will be June 10th.

You may make payment at the barn, via mail or PayPal (an additional $10 fee).

Once the form is received, we will contact to make arrangements for payment.
Payment:

In full amount $225$50 non refundable deposit
T-shirt Size

Youth smallYouth mediumYouth largeAdult smallAdult mediumAdult largeAdult XL
Payment options:

check via mailPayPal ( an additional $10)Other arrangements
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Twisted Pine Equine Center during the selected camp. In exchange for the acceptance of said child’s candidacy by Twisted Pine Equine Center, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Twisted Pine Equine Center 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 Twisted Pine Equine Center, 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, or death.
Medical Release and Authorization

As Parent and/or Guardian of the named athlete, 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 Twisted Pine Equine Center 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

MonthDayYear
Date
Signature

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Summer Camp Registration

Rider Information