December NH Riding Camp-2025

Winter Riding Program Registration

December 29-30
Rider's Name

PrefixFirst NameLast Name
Date of Birth
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Mother's Name

First NameLast Name
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Father's Name

First NameLast Name
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Home Number
Format: (000) 000-0000.
Physician Name

First NameLast Name
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Physician Number
Format: (000) 000-0000.
Insurance Company
Group #
Policy #
In Case of Emergency, Call:
Emergency Contact #
Format: (000) 000-0000.
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
Date

MonthDayYear
Enroll
prevnext( X )
Registration Fee (Required)
$275.00
Should be Empty:

Winter Riding Program Registration