December NH Riding Camp-2024

Winter Riding Program Registration

December 26, Dec. 30, Dec. 31 2024
Rider's Name*

PrefixFirst NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
E-mail*
example@example.com
Mother's Name

First NameLast Name
Home Phone
Cell Phone
Work Phone
Father's Name

First NameLast Name
Cell Phone
Work Phone
Home Number
Physician Name*

First NameLast Name
Physician Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Physician Number*
Insurance Company*
Group #*
Policy #*
In Case of Emergency, Call: *
Emergency Contact #*
Does the rider have any medical conditions or learning disabilities that we need to know about *
List all the medications that the Rider is currently taking: *
Briefly describe riding experience: *
In the case that I am unable to be reached, I hereby agree that Alison Eastman, Ann Grenier, and/or Apple Tree Farm staff in conjunction with medical personnel shall make medical decisions on my behalf, in my absence, while my child is participating in Apple Tree Farm activities.
Signature*

Clear
Date*

MonthDayYear
Enroll*
prevnext( X )
Registration Fee (Required)
$250.00
Should be Empty:

Winter Riding Program Registration