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
Rider Experience*

Beginner (0-10 rides)Intermediate: (11+ rides)Advanced (Years of riding)
Any known Medical problems or Allergies?
In the event of accident or injury I give Running Star Ranch management and/or staff permission to seek medical attention for my child named above.*

Yes
I give Running Star Ranch permission to use photos of my child on their Web site and social media.*

YesNo
Date*

MonthDayYear
Signature of parent*

First NameLast Name
How did you hear about us?
Level 1 Completed

Yes
Instructor
Level 2 Completed

Yes
Instructor
Level 3 Completed

Yes
Instructor
Level 4 Completed

Yes
Instructor
Level 5 Completed

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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