Student Registration

STUDENT NAME: _______________________________________________________________

ADDRESS:  ____________________________________________________________

                  ____________________________________________________________

CHILD'S DATE OF BIRTH:  __________________________________

PHONE: WORK _____________________ HOME _________________________  CELL ______________________

PARENTS' NAMES: _____________________________________________________________________________

PARENT E-MAIL:  ______________________________________________________________________________

EMERGENCY CONTACT NAME AND PHONE NUMBER: ____________________________________________________

DOCTOR NAME AND PHONE NUMBER: ______________________________________________________________

ALLERGIES: __________________________________________________________________________________

LEVEL OF RIDING EXPERIENCE: (CIRCLE ONE)     BEGINNER          INTERMEDIATE          ADVANCED          SHOWING

NUMBER OF YEARS RIDING: __________________

CAMP WEEK(S) SELECTION: ______________________________________________________________________

                        2012 Dates to Follow                          

SPECIAL INSTRUCTIONS:  _______________________________________________________________________

____________________________________________________________________________________________


PLEASE INCLUDE A $50.00 NON-REFUNDABLE DEPOSIT WITH YOUR REGISTRATION FORM.  THIS AMOUNT WILL BE CREDITED TOWARDS YOUR FINAL COST, WHICH IS DUE THE FIRST DAY OF CAMP. 

ALL CAMP RIDERS MUST HAVE A PARENT/LEGAL GUARDIAN SIGN A WAIVER OF LIABILITY RELEASE
PRIOR TO OR ON THE FIRST DAY OF CAMP.

Please PRINT AND MAIL this completed application and non-refundable deposit to:
Joy Kussman
Lakeside Equestrian Stable
1385 Churchville Road
Southampton, PA 18966

Checks are payable to: Joy Kussman
Questions? 215-355-3837