Camp/Workshop Registration 2024

Select Camp/Workshop*

Name

First NameLast Name

Birth Date (if over 18, this is not required)

MonthDayYear

Grade (if applicable)

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, food allergies, chronic illness, or medical conditions? If yes, please describe.*

Can your child be given benedryl or childrens motrin by an adult employee if needed?

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Dakota's Legacy Equine, LLC during the selected camp. In exchange for the acceptance of said child’s candidacy by Dakota's Legacy Equine, LLC. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Dakota's Legacy Equine, LLC, Mount Chance Farm 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 Dakota's Legacy Equine, LLC and Mount Chance Farm including all coaches/instructors 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 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 granted to Dakota's Legacy Equine, LLC. and its affiliates including coaches/instructors 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

Camp/Workshop Registration

Camper Information