White Fences Equestrian Center, Inc.

10908 Jones Road, Manor, Texas 78653

(512) 282-6248 • www.whitefencesaustin.com • info@whitefencesaustin.com

Summer Day Camp 2011

Camp Session #1: June 27th - July 1, 2011 • Camp Session #2: July 11th - 15th, 2011

NAME: __________________________________________________________

ADDRESS: _______________________________________________________

CITY/STATE/ZIP:_________________________________________________

WORK PHONE:__________________________ HOME PHONE:__________________________ CELL PHONE:___________________________

SEX:    M  /  F     BirthDate: _______ Age: ________ HEIGHT: ________ WEIGHT: ________

State law requires that we have the following on file: (Give last dates of immunizations and list all allergies).

Immunizations: DPT________MMR________TB_______Polio__________Other_________

Allergies: Insect Stings______Asthma______Food__________Other___________

Please use this space to supply White Fences with any information (physical, medical, social, psychological, etc.) that you feel will be helpful for us to know about working with this camper.




RIDING LEVEL?

______BEGINNER (little or no riding experience or lacks confidence)

______NOVICE (can ride a gentle horse at a walk, perhaps trot a little)

______INTERMEDIATE (can walk, trot, canter but needs to improve skills)

______ADVANCED (previous experience and instruction, good form & control)


2011 SUMMER DAY CAMP AVAILABLE WEEK REGISTERED FOR: (CIRCLE ONE)
(Be sure to call before submitting to be sure space in your age group is available the week you selected).

Camp Session #1: June 27th - July 1, 2011 ______ Age 5 to 8 ______ Age 9 to 13

Camp Session #2: July 11th - 15th, 2011 ______ Age 5 to 8 ______ Age 9 to 13


CAMP HOURS: 9:00a.m. to 2:00p.m

 

Early Drop off is at 8 am. Check here if needed __________

WHAT TO BRING: Each camper must bring a sack lunch, drinks, sunscreen and swimsuit.

TUITION: Payable in advance-by the week $295.00.
Early Drop off or Late Pick-up is available on request. There is a $25.00 fee for this service. Please check if needed.
Payment must accompany registration. Tuition is refundable, less a $25.00 office charge, only if alternate camper can be found to fill the cancelled space. Note: Tuition does not include noon meal. Each camper should bring a "sack" lunch and drinks. Soft drinks are available from the vending machines.

REGISTRATION WILL BE PROCESSED UPON RECEIPT OF REGISTRATION FORM AND PAYMENT. A CONFIRMATION LETTER OR PHONE CALL WILL BE GIVEN UPON ACCEPTANCE OF REGISTRATION.

White Fences Equestrian Center, Inc.

Summer Day Camp 2011

Camp Session #1: June 27th - July 1, 2011 • Camp Session #2: July 11th - 15th, 2011

NATURE OF THE HORSE: Horseback riding is classified as RUGGED ADVENTURE RECREATIONAL SPORT ACTIVITY, and there are numerous obvious and non-obvious inherent risks always present in such activity despite all safety precautions. No horse is a completely safe horse. Horses are 5 to 15 times larger, 20 to 40 times more powerful, and 3 to 4 times faster than a human. If a rider falls from horse to ground it will generally be at a distance of from 3 to 6 feet, and the impact may result in injury to the rider. Horseback riding is the only sport where one much smaller, weaker predator animal, the human, tries to control and become one unit of movement with another much larger, stronger prey animal, the horse, with each having a limited understanding of the other. If a horse is frightened or provoked it may divert from its training and act according to its natural survival instincts which may include, but are not limited to: stopping short; changing direction or speed at will; shifting its weight fro side to side, bucking, rearing, falling, biting, kicking or running from what it perceives as danger.

WARNING: UNDER TEXAS LAW (CHAPTER 87, CIVIL PRACTICES AND REMEDIES CODE), AN EQUINE PROFESSIONAL IS NOT LIABLE FOR AN INJURY and OR THE DEATH OF A PARTICIPANT IN EQUINE ACTIVITIES RESULTING FROM THE INHERENT RISKS OF EQUINE ACTIVITIES.

Signature of Parent or Guardian:_________________________________________Date:______________

PERSONS TO CONTACT IN CASE OF EMERGENCY

1. _________________________________________________________________________________________________________________________
    Name     Address     Home Phone     Cell Phone

2. _________________________________________________________________________________________________________________________
    Name     Address     Home Phone     Cell Phone

HEALTH INSURANCE INFORMATION

Name of Policy Holder:__________________________________ Address_________________________________________________________

Company:__________________________________________Policy No._________________________ Phone _____________________________

In the event that none of the above can be reached, instructors, agents and employees of White Fences are given permission to contact the necessary medical professionals and authorize emergency care medial treatment.

DOCTOR:__________________________PHONE:_________________ HOSPITAL:________________________________________________________


RELEASE OF LIABILITY:

It is further understood that White Fences Equestrian Center, Inc. and its instructors, agents and employees are hereby released from all liability with respect to any accidents that might occur. I also understand that White Fences Equestrian Center Incorporated does not provide accident insurance.

CONDITIONS OF NATURE AND INSPECTION OF PREMISES:
I understanding that: White Fences Equestrian Center, Inc. is not responsible for total or partial acts, occurrences, or elements of nature that can scare a horse, cause it to fall, or react in some other unsafe way. Some examples are: Thunder, lightening, rain, wind, wild and domestic animals, insects, reptiles, which may walk, run, or fly near, or bite or sting a horse or person; and irregular footing on out-of-door groomed or wild land which is subject to constant change in condition according to weather, temperature, and natural and man-made changes in landscape. The parent or legal guardian have inspected the instructional facilities and are satisfied that all premise conditions are reasonably safe for the rider's intended purpose, usage and presence upon White Fences Equestrian Center Inc..

Signed:_____________________________________ Print Name: ________________________________________Date:____________________