CHA Instructor Certification Clinic at SJ Riding Camp – Application

Please return this form to SJ Riding Camp, 130 Sandy Beach Rd., Ellington, CT06029.

Please include a non-refundable deposit of $250. Manuals will be mailed. The balance of $500 is due May 1.

Name: ______Age: ______Sex: ______

Home Address: ______Phone: ______

Please complete the following if you are being sent to this clinic by an organization.

Sponsoring Organization: ______Director or Contact Person: ______

Address: ______Phone: ______

Address for mailing clinic information, manuals, and medical form, if other than home:

______

Health and safety precautions are a priority at SJ and CHA.Any illness or accident requiring medical attention will be at your expense. These expenses are not included in the clinic tuition. The following information is therefore essential:

Medical Insurance Policy #: ______Ins. Company: ______

Place of employment

Name of Insured: ______or other group: ______

Who should we contact in case of emergency? ______Phone:______

Release and Authorization for treatment: The undersigned understands that horseback riding and its affiliated activities can be dangerous, and agrees to hold SJ Ranch, Inc., CHA, and staff, harmless in the case of an accident. In addition, I hereby give permission to the medical personnel selected by the camp to order x-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me/ my child. In the event I cannot be reached in an emergency, I hereby give permission for SJ Ranch to secure and administer treatment, including hospitalization, for the person named above.

______

Signature of participant 18 years of age or older Date Signature of parent or guardian if participant is under age 18 Date

Do you have any medical/physical problems which might be affected by riding, camping or which we should be aware of?

______

Briefly describe the type of riding that you do and you riding experience, including horse care and management experience.

Please describe your experience in teaching riding and/or other forms of teaching or work with young people (teaching school, swimming, camp counselor, work with youth groups, etc.)

If you plan to teach riding after taking the clinic, please describe the type and size program you plan to work in and what your duties will be.

What do you hope to accomplish by attending this clinic? Do you have any special problems or interests that you would like to see covered in this clinic?

1/5/18

Please add additional pages as needed.