EmailMe Form - Horsemanship Summercamp Registration 2017

Horsemanship Summercamp Registration 2017
High C Acres

Choose Camp Weeks (FULL DAY from 7.30 am to 3 pm) FULL

FULL: Week 1-May 30-June 2 (4 days)

FULL: Week 2-June 5-June 9

FULL Week 3-June 12-June 16

FULL: Week 4-June 19-June 23

FULL Week 5-June 26-June 30

Name (Parent Guardian) *

Address
(required)

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Phone *

Email *

Confirm *

Camper's Address if different from parent/guardian

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Alternate Contact 1

Prefix

First

Last

Suffix

Middle

Phone Number for alternate contact 1

###

####

Alternate Contact 2

Prefix

First

Last

Suffix

Middle

Phone Number for alternate contact 2

###

####

Camper's Name *

Prefix

First *

Last *

Suffix

Camper's Birthday

YYYY

MEDICAL RELEASE INFORMATION

Child's Name *

Primary Emergency Contact Name *

Relationship *

Phone Number Primary *

###

####

Secondary Emergency Contact Name

Phone Number Secondary *

###

####

Relationship *

Doctor's Name *

Doctor's Phone Number

###

####

Does your child have any allergies, medical conditions, or other special needs? Please specify what your child is allergic to and
what reaction is typical. It is especially important that we learn about allergies to bee stings and foods.

Will your child be taking any medication while at High C Acres? If so, please detail:
(Any medication your child will be bringing to camp should be in a secure container clearly labeled with his or her name.)

In the event of an emergency, if we cannot reach you, please indicate your permission to authorize emergency care by checking the approriate field.

I authorize emergency care if I cannot be reached in the event of an emergency

I DO NOT authorize emergency care if I cannot be reached in the event of an emergency

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