Summer Camp Registration Form
Camper's Information
Camper Name
*
Nickname
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
Year
Camp Registering For?
*
Please Select
June 22 - 26
July 20 - 24
August 3 - 7
T-Shirt Size
Please Select
YS
YM
YL
AS
AM
AL
AXL
AXXL
Camper Swimming Ability
*
Non-Swimmer
Beginner Swimmer
Experienced Swimmer
Please provide a brief description of the child's horse related experience
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Parents' Information
Parent/Guardian 1
Parent/Guardian 1
*
First Name
Last Name
Relationship to Child
*
E-mail
*
example@example.com
Cell Phone
*
Format: (000) 000-0000.
Home Phone
*
Format: (000) 000-0000.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where would you like to be reached while your child is at camp?
*
Cell Phone
Home Phone
Other
Parent/Guardian 2
Parent/Guardian 2
*
First Name
Last Name
Relationship to Child
*
E-mail
*
example@example.com
Cell Phone
*
Format: (000) 000-0000.
Home Phone
*
Format: (000) 000-0000.
Home Address Same as Parent/Guardian 1?
Yes
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where would parent/guardian 2 like to be reached while your child is at camp?
Cell Phone
Home Phone
Other
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Authorized Pickup
should at any time your child be picked up by someone other than the parent(s) or guardian(s) listed above, please enter their information below
Authorized Pickup #1
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Format: (000) 000-0000.
Secondary Phone Number
*
Format: (000) 000-0000.
Relationship to Child
*
Authorized Pickup #2
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Format: (000) 000-0000.
Secondary Phone Number
*
Format: (000) 000-0000.
Relationship to Child
*
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Medical / Health Information
Does your child have any food, medication or environmental allergies?
*
Yes
No
Allergies? Check all that apply
Food
Medication
Environmental
Please list and explain any allergies
0/150
Does your child’s allergy/allergies require child care staff to monitor child for symptoms, take action if a reaction occurs, or give emergency medication to your child?
Yes
No
Does your child have a special health or medical condition?
Yes
No
Please explain
0/150
Is your child currently using any medication, food supplement or medical food (such as electrolyte solution)?
Yes
No
Please explain
0/150
If yes, does this medication, food supplement, or medical food need to be administered at the day camp?
Yes
No
Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?
Yes
No
Please explain
0/150
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List any additional information about your child that would be useful for staff to know, such as fears, eating habits, or special routines. This information should not be medical or health related, as that information should be included in the previous questions.
0/200
Additional Medication
Check all that apply
Prescription medication
Nonprescription medication
Refrigeration required
Topical product or lotion
Topical product or lotion
Food supplement
Modified diet
Name of medication
Exact dosage
To be administered at the following times
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Mack Hill Riding Academy has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported.
*
Type first and last name above to consent
Sign Document
*
Date Signed
*
-
Month
-
Day
Year
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