Stillwater Farm & Arena, LLC Summer Horseback Riding Camp

Camper's Name*

First NameLast Name

So that we can best group your camper, please list any experience has your child had with horses in the past? Please clearly explain if your child is able to ride independently or will need close assistance as in a 1:1 instructor. Please include any other equine activities your child has participated in.*

We are planning to hold camp during the following dates. In an effort to make camp the most efficient and to ensure all campers have a great time, it's important for us to be able to group riders by their levels of ability. Therefore, please mark ALL WEEKS THAT YOU CAN ATTEND.

June 3-6June 24-27July 8-11

Daily Camp times are 8:45 am - 3:00 pm each day. Early drop off (7:30 am) and later pickup (4:30 pm) are available for an additional cost. Check all that apply.

I will need to drop my child off early, and understand that it will cost me an additional $10/ day for each early drop off.I will need to pick my child up later than 3:00 pm and understand that it will cost an additional $10/ day for each late pickup.

Age of camper during camp:*

Grade camper will be entering:*

Gender*

MaleFemale

What size shirt does your child wear?

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name*

First NameLast Name

Cell Number*

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Alt. Phone Number*

If you're interested in volunteering during the week, please list your name below. Nicki will reach out to talk further!

Does the camper have any allergies, chronic illness, or medical or cognitive conditions? If yes, please describe. Please enter N/A if there are none.*

Lunch and Snacks will be provided each day. Please list any common foods that your camper WILL NOT eat.

Is there any other information you'd like the camp coordinators to know?

All information will be kept confidential.

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 Stillwater Farm & Arena, LLC and its affiliates including Instructors and Volunteers 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 camp.

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

NON-REFUNDABLE DEPOSIT- Your registration WILL NOT BE officially received until your deposit payment clears through one of the following methods. NOTE- PUT "CAMPER'S NAME- CAMP DEPOSIT" IN THE NOTE SECTION. Venmo- @nicki-jones-16 PayPal- nickijones78 Zelle- 859-391-9880 Deposit- $100/camper, with balance due the first morning of camp via cash, check or a method above. Siblings discount is 10% off the second camper's balance due after the deposit is paid.

Deposits will only be refunded if the spot can be filled.

Camp Details

Camper Information