Summer Camp Registration Form 2008

Participant Information

Student’s Name (last)______(first)______Date of Birth ______

Address______

Parent/Guardian’s Name______

Home #______/Work #______/Cell #______/Email______

Student handling experience w/horses (circle all that apply): no experience grooming

tacking leading feeding/watering saddling/bridling stall cleaning first aid

Students riding experience with horses (circle all that apply): no experience pony rides trail ride at horse rental stable walk trot/jog canter/lope jumping horse shows

Other: ______

Summer Camp Enrollment 2008

Monday-Friday 8:30am to 4:30pm*

Students may register for more than one session. Please check the session(s) for enrollment. Please also check if before care and /or after care is desired.

ÿ Session 1: June 23-27 ÿ Session 2: July 21-25 ÿ Session 3: August 11-15

ÿ Before Care: 7– 8:30am – addtl. $25 per session/ ÿ After Care: 4:30 – 6 pm addtl. $25 per session

Schedule of Payment for Summer 2008: $300* (per 1 week session)

*A 10% discount (total due $270) will be given for only one of the following:(credit card payments subject to a $10.00 additional processing fee- total due $280)

1. Participants registering for more than one session.

2. Multiple participants registering from same household.

3. Payment in full at time of registration, prior to June 1, 2008.

Payment plan: Total due $300 (per session) made in two payments

#1 Due at Registration $100

#2 Session 1-May 15, Session 2-June 15, Session 3-July 15 $200

There will be a $10 late fee for each installment not received by the due date. A $10 late fee will be assessed on a weekly basis thereafter until the installment is paid.

I understand and agree to comply with payment schedule. By signing below, I acknowledge that I am registering for the indicated session(s). I am obligated to pay for the entire session unless authorized personnel grant an emergency exception. Refund Policy: A $100 non-refundable registration fee will apply to all sessions.

Parent/Guardian Signature______Date______

Parent/Guardian Name______

Payment type :Check /Money order/ Cash/Visa/MC/DISC/AMEX

Payment #1______Check #______Date______Rec’d by______

CC#______Exp. Date______

Payment type :Check /Money order/ Cash

Payment #2______Check #______Date______Rec’d by______

CC#______Exp. Date

Participant Profile Form

Participant Name Participant Birthdate (M/D/Y) Age M / F (circle one)

______

Address City/State/Zip Code County

______

Mother/Guardian Name (H) (W) (Cell)

______

Father/Guardian Name (H) (W) (Cell)

______

Emergency Contact Name (H) (W) (Cell)

(other than parent/guardian)

______

Primary Care Provider/Clinic Name Phone Number (where medical records are kept in case of emergency)

______

School attended this year City/State

______

Please note: The Maryland Department of Health and Mental Hygiene Immunization Certificate must be attached to this form for any participant (ages 18 or under) who did not attend a Maryland public or private school this year (i.e. home-schooled, out-of-state schools). Program staff can provide you with this form.

Is the participant exempt from immunizations for religious or medical reasons? _No _Yes If yes, the Maryland Department of Health and Mental Hygiene Immunization Certificate must be completed and attached to this form. Program staff can provide you with this form.

_ Date of last tetanus or DPT shot ______Month/Year (REQUIRED BY MARYLAND STATE LAW FOR INDIVIDUALS UNDER 18)

_ Are there any health issues/concerns (i.e., seizures, asthma, allergies)? _ No_ Yes If yes, please explain. ______

______

If yes for asthma/allergies, will an emergency medical device (epi-pen/inhaler) be provided? _No _ Yes

Is your child currently taking any medication? _No _ Yes If yes, an additional medical form must be completed. Staff can provide you with the form.

Are there any physical, psychiatric, behavioral, emotional, or developmental concerns staff should be aware of?_ No_ Yes

If yes, please explain. ______

_ Participant is a _ Non- rider (no experience) _ Beginner Rider (walk/some trot) _ Intermediate Rider (walk/trot/some canter)

_ Advanced Rider (walk/trot/canter/maybe jumping/ showing/patterns)

I hereby represent and warrant that if the participant is a minor, I am his/her guardian and authorized to provide the releases, authorizations, and permissions as stated below and all information above is accurate and complete. I hereby give permission for the applicant to participate in all program activities, including field trips in vehicles and agree to release Lockhaven Ranch, its officers, employees, and agents, from all liability arising from any harm or injury incurred by the participation of my child in the program stated above. Unless otherwise indicated by a parent/guardian in writing at the time of registration, photographs of participants for use in Lockhaven Ranch publications may be taken while participating in the program activities. No personal information other than the participant’s name will be released under any circumstances except as required by law. By way of copy of this form, I authorize the staff of Lockhaven Ranch to obtain medical/hospital treatment for the above participant in the event of an emergency.

If participant is 17 or under:

Print parent/guardian name Date Signature

If participant is 18 or older:

______

Print participant name Date Signature

This form must be completed for every participant.

_ Mail forms to: Lockhaven Ranch 7034 Kent Rd. Sunderland, MD 20689 (301)-455-0993

Lockhaven Ranch

RELEASE, WAIVER AND INDEMNITY AGREEMENT

I/WE/PARENTS of ______(if a minor, age _____), understand and assume the risk of all and any injury that may occur to ME/US/OUR CHILD, and property during, prior to or after any equine activities held at the property known as Lockhaven Ranch, for which the facilities are located in Calvert County, Maryland or at an off- premises event participated in/with Lockhaven Ranch.

I/WE understand and acknowledge that any involvement with horses can be extremely dangerous. I/We voluntarily and expressly assume all liability and risks knowing fully the possibility of injury and death, regardless of the cause of such injury.

In consideration of having been forewarned of the possibilities of injuries that may occur as a result of any activities, either precedent to, during or after any equine activities at Lockhaven Ranch as described above we do agree by this instrument not to sue Lockhaven Ranch or its agents, employees, and members. I/We or heirs waive and release any and all claims arising out of such equine activities or the use of such property, including, but not limited to claims alleging negligence, strict liability, breach of contract, loss of severance of Lockhaven Ranch. This agreement to not sue includes claims for bodily injury, property damage, death or any other claim, which I/We and my/our heirs may have against Lockhaven Ranch.

Sanctioned ASTM/SEI riding helmets are required to be worn at all times by riders under the age of 18 years, and is encouraged for riders 18 years of age and older.

I/We also acknowledge and agree that I/We have, or it is our responsibility to obtain and keep in force, sufficient insurance coverage (including but not limited to liability, health and life) to protect me/us from any expense, liability claims, or damages mentioned or included in this agreement, and that whether or not I/We obtain such insurance and whether or not such insurance is sufficient, the provision above shall be fully effective and enforceable and we will be bound and liable there under.
Rider’s Signature______Date______