T.E.A.D.'s Summer Camp 2010 Registration Form

Name:_________________________

Date of Birth: d____m____y______

 

Phone Numbers: (h)_______________(w)_______________(c)_______________

 

Address:________________________________________

 

Parent / Guardian Name and Contact Number:____________________________

 

Emergency Contact (if different from above):_____________________________

 

Allergies:___________________________________________________________________

 

Procedure in case of reaction:________________________________________

 

Medication:_________________________________________________________________

 

for:_______________________________________________________________________

 

Doctor:_______________________

Health Card #: ____________

 

Approx height/weight: ____/____

Riding Experience : __________________

 

___________________________________________________________________

 

Does the camper have any type of disability? y___n___

 

If yes, additional form and medical form must be submitted 2 weeks before session

 

Dates

Select a week & provide a second choice (space permitting)

Week 1 - July 5 - July 9	________________
Week 2 - July 12 - July 16	________________
Week 3 - July 19 - July 23	________________
Week 4 - July 26 - July 30	________________
Week 5 - August 3 - August 6	________________
Week 6 - August 9 - August 13	________________
Week 7 - August 16 - August 20	________________
Week 8 - August 23 - August 27	________________

 

Release and Authorization

 

In consideration of other valuable consideration and the treatment therapy and assistance that you have agreed to give me; I __________________________________________ on behalf of my heirs, administrators and assigns, hereby acknowledge that I am participating in the program and activities connected therewith concluded by you at my sole risk and I exonerate and release you, your agents, volunteers, employees and all who act on your behalf from all responsibility and claims for any injury that I may suffer while participating in such a program.

 

Signed:_______________________________________

Dated: ___________

 

Witness: ___________________________________

Dated: ___________

 

Photo Release

 

In consideration of T.E.A.D. continuing to provide services to the community, I hereby: a) grant permission for the said association and all members of it's staff to take and use still and moving photographs or film, including television pictures of (insert childs  name)_______________________________.

 

Signed: ____________________________________

Dated: ________________________________