Misty Brae Farm LLC
Registration Form
Spring Break Camp March 25 - 29, 2013
I/We, ______
(Please print name(s) of parent(s) or legal guardian(s)
grant permission for our child to attend and participate in all Misty Brae Farm Spring Break Camp activities, on and off Misty Brae Farm LLC (MBF) premises, during camp hours from 9:00 am to 4:00 pm. I/We realize that safety precautions will be taken and that my child will be supervised but that MBF assumes no liability for injury or damages incurred. In the event that I/we cannot be reached in a timely manner, I/we give permission for my/our child to receive emergency medical treatment, as necessary, and I/we want to be notified immediately. Any debt incurred will be the responsibility of the parent or guardian. I/We also give MBF permission to use his or her photographic likeness in all forms for media advertising and other lawful purposes.
Signature of Parent/Guardian Signature of Parent/Guardian
Session(circle choice)
Full Day: $475 (9:00am – 4:00pm) Half Day: $350 (9:00am – 1:00pm)
Camper & Contact Information
Camper’s Name: ______Age: ______
Current Grade: ______Shirt Size: ______(available in Youth, S, M, L Adult S , M)
Father: ______Email:______
Address: ______
City:______State:______Zip:______
Phone #’s: Home______Work ______Cell______
Mother: ______Email: ______
Address: ______
*If same as father’s address indicate same.
City: ______State: ______Zip: ______
Phone#’s: Home______Work ______Cell______
Email: ______
Brief Description of Riding Experience:
Emergency Information:
Physician: ______Phone: ______
Insurance Company Name:______Policy Holder:______
Policy & Group #’s: ______Phone:______
Please list Emergency Contacts and/or people who have permission to pick up your child.
Name: ______Phone:______
Name: ______Phone: ______
Please check or indicate any medical information that would help us to better care for your child.
Asthma ___ Inhaler ___ Bee Allergies ___ Nut Allergies ____ Other______
Payment Information:
A $100 non-refundable deposit is due with this registration. Full payment can also be submitted with the registration form. Any remaining balance is due on the first day of camp. Please make the checks out to Misty Brae Farm.
If paying by credit card, please provide the following information and we will charge the card on the first day of camp.
Credit Card: ______
Account Number: ______
V-Code: ______(3 digit code on back of card) Exp. Date:______
I understand and authorize all payments due must be charged due to a space being “saved”. I also understand that Misty Brae Farm does not provide refunds or credits for missed days. Policies are posted on the website and available in the office. I have read, understand, and agree to all payment policies.
Card Holder Signature:______ Date: ______
Must be signed by the cardholder. No other signatures accepted.
Please return this form, along with deposit (or complete payment) to:
Misty Brae Farm, P.O. Box 13, Aldie, VA 20105
MBF Spring Break Camp Registration Form 1