Child

First Middle Last Gender: MaleFemale

School Name Grade Birth date : Age (as of June 30, 2011):

Street Address :

Town/City: State: Zip code: Child’s Home Phone:

Parent/Guardian - Contact Information

Parent/Guardian #1

First Last Ms.Mrs.Mr. Other

Street Address :

Town/City: State: Zip code: Home Phone: Work Phone:

Cell phone: FAX: E-mail:

Occupation:   Employer:

Parent/Guardian #2

First Last Ms.Mrs.Mr. Other

Street Address :

Town/City: State: Zip code: Home Phone: Work Phone:

Cell phone: FAX: E-mail:

Occupation:   Employer:

Child lives with:

Person responsible for payment:

Emergency Contact Information – Alternate Pickup/Release

Emergency Contact #1

First Name Last Name Home Phone Work Phone

Cell Phone E-mail Relation to child

Emergency Contact #2

First Name Last Name Home Phone Work Phone

Cell Phone E-mail Relation to child

Please list those people including in addition to parents/guardians who are permitted to pick up your child:

1:  2:3:

Medical Release Information

Insurance Information

Policy Number:    Name of Health Insurance Provider:

Primary Physician:  

Address:  

Phone: Hospital Preference:

Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).

Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?

Is your child allergic to any type of food or medication?

Does your child require a special diet?

The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.

In case of medical emergency contact:

	Name	Phone #	Relationship to Child
Contact #1
Contact #1
Contact #1

I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.

I understand that the Family Horse Academy Inc Mini-Camp will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.

*TUITION INFORMATION, If your child/children will not bring food or doesn’t have any transportation we will charge an extra $25 to help cover food and transportation cost.

Please circle how you heard about the Family Horse Academy Inc. Mini-Camp.

Terms of Agreement

Photo Release

I hereby give permission for my child to be photographed during the Family Horse Academy Inc. Mini-Camp. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of Family Horse Academy.

The Family Horse Academy Inc. and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. Children's’ photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician).