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: __________________
After School Horse & Pony Club SESSION SELECTION: _____________________________________________________________________
SPECIAL INSTRUCTIONS: _______________________________________________________________________
____________________________________________________________________________________________
PLEASE INCLUDE A $100.00 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
Joy Kussman
Lakeside Equestrian Stable
1385 Churchville Road
Southampton, PA 18966
Checks are payable to: Joy Kussman
Questions? 215-355-3837