Old Mill Farm Stables
Summer Riding Camp
June 18-22 and 25-29

                                                         Registration Form      Camp Dates:____________

Name of Participant:___________________________________ Age:_________ 

Parent/Guardian Name:_____________________________________________

Address:_________________________________________________________

Phone:__________________________ Cell:____________________________

Emergency Contact Name:__________________________________________

Relationship to camper:_____________________________________________

Phone Number:__________________________ Cell:______________________

Medical Information:

Does camper take any medications?  Y   N    If Yes, list below:__________________
__________________________________________________________________

Allergies? Y   N    If yes, list below:________________________________________
__________________________________________________________________

Does Camper have any medical conditions,limitations or problems?____________
_________________________________________________________________

Name of Doctor:__________________________ Phone:_____________________

Preferred Hospital in case of emergency:__________________________________

Insurance Carrier:___________________________ Pol #:____________________

Medical Release:

I/We, the parent/guardian of ___________________________ , give consent and permission to Ashlyn Staley to render first aid, administer medication, summon an ambulance or provide transport for my child to receive emergency care in the instance that it be required. 

Parent/Guardian Signature:_____________________________ Date:___________