Running Star Ranch 2016 Horse Camp Registration Form

Riding Lesson Intake Form

Running Star Ranch
Name of Student*

First NameLast Name
Birth Date*

MonthDayYear
Height*
(For purposes of matching riders with horses)
Weight*
(For purposes of matching riders with horses)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mother's Name*

First NameLast Name
Mother's Phone Number*

Area CodePhone Number
Mother's E-mail
Father's Name*

First NameLast Name
Father's Phone Number*

Area CodePhone Number
Father's E-mail
Additional Emergency Contact*
Phone Number of Emergency Contact*

Area CodePhone Number
Who has permission to pick up student
Beginner (0-10 rides)Intermediate: (11+ rides)Advanced (Years of riding)
Any known Medical problems or Allergies?
Yes
YesNo
Date*

MonthDayYear
Signature of parent*

First NameLast Name
How did you hear about us?
Yes
Instructor
Yes
Instructor
Yes
Instructor
Yes
Instructor
Yes
Instructor
Payments can be made online, in person, or sent via mail.

Running Star Ranch, 24423 Country View Drive, Kearney, MO 64060
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