Summer Camp Application

ttp://www.renegadefarm.com - Summer camp

APACHE TIER HORSE CAMP

5489 Mariaville Rd

Schenectady, NY 12306

Lynn@renegadefarm.com

You may print this form, complete it and mail it to the address above or bring it directly to the farm.

 (518) 864-5518 fax (518) 557-0178

Horse Enthusiast Name_________________________________________________________________

_M___F___

Date of Birth________________  Age______Grade Sept. 2010_________Height________Weight_______

Home Address_____________________________________________________________________

____________________________________________ Home Phone Number________Cell phone_________

Email address:_________________________________

Mother’s Name________________________________ Daytime Phone________________________

Father’s Name_________________________________Daytime Phone_________________________

If parents are divorced or separated, who has custody?_____________________________Not applicable_______

Who will pick up child from camp each day?___________________________________________(only this designated person(s) will be permitted to pick up your child from camp)

Emergency Phone Number and person to contact________________________________________

_______________________________________________________Relationship to camper_____________

Riding preference: Western_______English_____ No preference_______                                                                                                                                                                 

In the last two years, camper has ridden horses: less than 10 hours  _________                                                                     10 to 20 hours_________     20 hours or more__________ consistently for 2+ years____________________

Indicate where student has ridden previously_____________________________________________

Please check all weeks attending camp (indicate your preference with 1, 2, 3, etc. with 1 being your first preference): Each week is limited to 5 students! Minimum age for  camp is 7 yrs;

Enrollment:

$75.00 non-refundable deposit is due by May 30, 2010 for the 3-day sessions and a $125 non-refundable deposit is due by May 30, 2010 for the 5-day sessions. Balance due in full by June 20, 2010.  A $25.00 fee will be assessed for each returned check. Make checks payable to Apache Tier Horse Camp, mail to 5489 Mariaville Rd.; Schenectady, NY 12306
 
No camp fee will be refunded after 7/1/10 or once camp has started.

Indicate which fee plan you would like:

5 day camp: Weekly fee:  $280.00__________

3-day camp:  $165.00______________

Discounts available:

$5.00 discount per student when 2 or more students from same family enroll

$5.00 /student for returning students

$10.00/student if full payment is received by May 15, 2010.                                   

Upon receipt of the non-refundable deposit per student, an invoice & liability release form will be sent approximately 30 days from start of camp.  The liability release form must be signed and returned prior to the start of camp or the child will be unable to participate in the horseback riding activities...

All students are required to wear ankle length pants. Riding boots and approved riding helmets will be supplied.

Medical History

Family or camper’s medical insurance company___________________________________________________

Policy#______________________ Name of Insured______________________Employer__________________

Are there any special or medical problems we should be aware of?  Yes______ No____ if yes, please describe___________________________________________________________________________

____________________________________________________________________________________

PARENT AGREEMENT

My child may attend Apache Tier Horse Camp and I hereby certify that he/she is capable of participating in the horse activities.  I understand the camp does not carry health and accident insurance and that I am responsible for health incurred costs.

I also grant Apache Tier Horse Camp and its agent’s full authority to take whatever actions they deem necessary regarding my child’s health and safety, and I fully release the Princetown Horse Farm LLC d.b.a. Renegade Farm/Apache Tier Horse Camp from any liability in connection with those decisions.  I understand my child must comply with camp rules and standards of participant behavior.  I agree that Apache Tier Horse Camp has the right to enforce appropriate standards of conduct and may dismiss, without a refund, any camper who infringes on the rights of others.

Further, I give my consent for the use of any photographs, slides or video tapes, which may include my child to be used in the Princetown Horse Farm LLC d.b.a. Renegade Farm/Apache Tier Horse Camp promotional materials.

Parent Authorization for Treatment

In the event I can not be contacted in an emergency, I hereby give permission to the physician selected by the camp director to hospitalize and to secure treatment for my child.  

The child named on this enrollment form has my permission to engage in all horse related activities of Apache Tier Horse Camp except as noted on the form by me.

_____________________________________            ___________________________________________

Print Parent/Guardian Name                                          Signature of Parent/Guardian                Date