2010 Statesman Farm
Summer Camp Registration Form
Childs Name: _________________________ DOB: ______________________
Parents: ______________________________ Daytime #: __________________
Address: ______________________________ Cell #: ______________________
Email: ________________________________________________________________
Registration for the week of: Early Drop off: Late Pick Up:
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June 14 – 18 @ ___________ @ ___________
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June 21 – 25 @ ___________ @ ___________
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June 28 – July 2 @ ___________ @ ___________
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July 05 – 09 @ ___________ @ ___________
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July 12 – 16 @ ___________ @ ___________
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July 19 – 23 @ ___________ @ ___________
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July 26 – 30 @ ___________ @ ___________
Total: ___ Camp Weeks X $ 275
Early Drop Off $ 10 x ____ $ ____________
Late Pick Up $ 10 x ______ $ ____________
Total Due $ ____________
Less 50% Deposit (non-refundable)$ (__________)
Balance Due (14 Days Prior) $_____________
Please explain your child’s riding experience. Is your child currently in a lesson program? If so, where, for how long and what is he/she doing in lessons?____________________________________________________________________________________________
Does your child have any food allergies, activity restrictions or health issues that we need to be made aware of? Will your child need to be given any special medications during camp? _________________________________________________________________
Who has permission to drop off and/or pick up your child from camp? Name and phone number:
____________________________________________________________________________________________________________
Primary Care Doctor: ______________________________________ Phone: ___________________________________________
A few reminders:
- 1. Children are required to have their own ASTM approved riding helmet.
- 2. Proper shoes (hard-soled, enclosed boot, with a heal) are required. If your child does not have the proper shoes they will not be allowed to ride on that day of camp.
- 3. Long pants are required for mounted lessons each morning. A change of clothes for other activities is also suggested for afternoon activities.
- 4. Children should bring their own bag lunch drinks and snacks. A refrigerator is available for food storage and beverages.
- 5. Riding equipment (ask for the beginners package) may be purchased at _________________
I have read and understand the camp brochure as well as the liability release agreement.
Parent Signature & Date