Summer Horse Camp 2019 Registration Form

Summer Camp Registration 2019

Summer Horse Camp for children of all abilities between 5-10 years old
Camp Information
- Cowboy Town Stables' Horse Camp is a truly inclusive camp for children with special needs and typically developing children between 5 and 10 years old.
- Our specially trained instructors provide lessons for people of all abilities. They are certified through the Professional Association of Therapeutic Horsemanship International.
- Please note that riders who require one-on-one attention for behavior management or daily living skills must come with an assistant. This ensures that centre staff and volunteers are not overburdened and are able to attend to all campers.
- Below you will be asked to complete the Registration, Rider Information, Photo Release, the Release of Liability and Emergency Medical Authorization. Please be sure to complete all sections. We will need these to be completed even if you have attended a previous camp or have ridden with us before.
- Release of Liability and Emergency Medical Authorization Forms also need to be completed by anyone attemding the camp with the camper (for example parents or assistants that wish to stay) along with all other visitors. Please email us for hard copies if you require this.
- If you have any questions, please contact Clare on 326-2464 or email clare@cowboytownstables.com
Camp is running on 2-5 July (Week 1, Tues-Fri) and 8-12 July (Week 2, Mon-Fri) from 8:30am-12pm daily.

Campers can attend on a daily or weekly basis.

Camp is CI$55 per individual day, CI$200 for the full week 1 and/or CI$250 for the full week 2.

In order to ensure a spot, a deposit of $100 is required for registrations made before 3rd June; thereafter, full payment is due with registration. Please make cheques payable to Shanna Scott. You can also pay online to our Bank of Butterfield account – just let us know and we will provide the account information.

There will be a maximum of 15 campers per day.
Please select preferred dates of attendance:*

All datesMonday 8th JulyTuesday 2nd JulyTuesday 9th JulyWednesday 3rd JulyWednesday 10th JulyThursday 4th JulyThursday 11th JulyFriday 5th JulyFriday 12th July
Camper Registration
Camper's Name*

First NameLast Name
Birth Date*

MonthDayYear
Age*
years old
Height*
ft, in / cm
Weight*
lbs
Gender*

MaleFemale
Physical Address*

Street Address

House name / number

TownDistrict

Country
School*
Please list any diagnoses:
Allergies
Any conditions / restrictions we should be aware of?
Previous experience with horses?*

Regular experienceSome/a little experiencePrevious camperNone
Parent/Guardian Information
Name*

First NameLast Name
Cell Number*

Area CodePhone Number
Alternative Number

Area CodePhone Number
E-mail*
Address (if different from camper's address)

Street Address

House Name/Number

TownDistrict

Country
Employer*
Relationship to camper*
Caregiver contact details (if applicable)
Rider Information

This information may be used by Cowboy Town Stables staff to assist in tailoring camp activities to best meet the needs of campers.

Please complete the below to the best of your knowledge.
Please describe the camper's personality*
What are the camper's favourite toys, interests and activities?*
What are the camper's fears/dislikes?*
Include any tactile, smell and/or hearing sensitivities
Does the camper know/understand the following (check all that apply)?:
Educational / cognitive*

Knows numbersKnows lettersKnows left/rightKnows prepositionsDescribes feelingsMakes choicesFollows 1 step directionFollows multi-step directionGood problem solving skills
Social*

Recognises nameWaves hello/goodbyeKnows"No"shares toys/itemsUnderstands rulesAppropriate touchingInteracts with peersAppropriate conversationMakes eye contact
Language*

Makes sounds/gesturesSays wordsCombines 2 or more wordsSpeaks in complete sentencesUnderstands simple conceptsUnderstands complex conceptsSounds out wordsRecognises sight wordsReads sentences
How does the camper communicate?*
Check off the physical skills that apply to the camper:*

Stand on 1 footHop/jumpSkipWeight bearing on handsHold objectRelease objectDresses selfRides a bikePlays sportsKick a ballCatch a ballOpens doors/containersUses utensils/toolsManipulates fastenersPlays on swingWrites legibly
What are the camper/family goals from our camp?*
Photo Release

Please confirm whether you do or do not consent to and authorise the use and reproduction by Cowboy Town Stables of any and all photographs and any other audio/visual materials taken of you/your child/your ward for promotional material, educational activites, exhibitions or for any other use for the benefit of our program.
Please choose from the following photo release options:*

I do consentI do not consent
Release of Liability

Horses, young and old, react differently and unpredictably, in different situations and environments. I, the parent(s) and/or legal guardian(s) of the above named camper, understand the risks involved in the equine sport, including, but not limited to, the handling, medical care, grooming, bathing, stall cleaning, feeding, watering, training, saddling and unsaddling, and riding of horses as well as just being around them.

I acknowledge that being around horses and taking part in any aspect of the sport of riding, are inherently dangerous activities and I assume and accept all liability for any injury, disability, death, or loss or accidental damage that might arise and hereby agree to hold harmless Shanna Scott Pandohie, Anthony Pandohie, their family, Cowboy Town Stables, directors, agents, employees, trainers, volunteers and other participants, if applicable, owners and lessee(s) of premises used to conduct any horse related activities.

I hereby certify that I am covered by medical, health and accident insurance and/or I am responsible for any costs I may incur for my own medical injuries.

By signing this release and waiver, I am assuming all risks of this activity in which I will be engaged and releasing all of the parties indicated above of any and all liability for their negligence of any description whatsoever. It is my intent to assume all risk and to waive and give up my rights (for myself and my heirs) to sue. And I do so knowingly and voluntarily.
I agree to the above release of liability:*

Yes
Camper Name*

First NameLast Name
Parent/Guardian Name*

First NameLast Name
Physical Address*

Street Address

House Name / Numbeer

TownDistrict

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Date

MonthDayYear
Date
Authorization for Emergency Medical Treatment
Physician's Name*

First NameLast Name
Physician's Number*

Area CodePhone Number
Preferred Medical Facility (if any)
Health Insurance Company*
Policy #*
Any allergies to medications?
Any current medications?
PLEASE CHOOSE ONE OF THE FOLLOWING EMERGENCY MEDICAL TREATMENT PLAN OPTIONS:

Consent Plan

In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the property of the agency, I authorize Cowboy Town Stables to:

1. Secure and retain medical treatment and transportation if needed.

2. Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.

This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed “life saving” by the physician. This provision will only be invoked if the person(s) above is unable to be reached.

Non-Consent Plan

I DO NOT give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency.

A parent/legal guardian will remain on site at all times during equine-assisted activities

OR
In the event that emergency treatment/aid is required, I wish the procedure explained in the box below to take place.
Please choose from the following emergency medical treatment options:*

I consentI do not consent
If you have chosen the non-consent plan, please detail the procedure you wish to take place:
Parent/Guardian Name*

First NameLast Name
Date

MonthDayYear
Date
Confirmation

BY ACKNOWLEDGING AND PRESSING THE SUBMIT BUTTON BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE FOR ALL SECTIONS ABOVE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THIS ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Should be Empty:

Summer Camp Registration 2019