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K.C.
Academy CAMP Program
APPLICATION FOR ENROLLMENT
Student Name
Last
First Nickname
Birth date
Age
Month
Date Year
Home Address
City
State Zip
Home Telephone ( )
Business Address and Phone:
Emergency Contact
Name/Relation:
Phone
Please Mark which Camp you wish to Attend:
Beginning Horsemanship Camp
□
March 19 - 23, 2006, 10:00 am - 4:00 pm- Beginning Camp
□
March 26-30, 2006, 10:00 am - 4:00 pm- Combined Camp (Beginning
& Intermediate Camp)
□
June 18 - 22, 2006, 10:00 am - 4:00 pm - Beginning Camp
□
June 25 - 29, 2006 10:00 am - 4:00 pm - Intermediate Camp
□
July 16 - 20, 2006, 10:00 am - 4:00 pm - Beginning Camp
□
July 23-27, 2006, 10:00 am- 4:00 pm - Intermediate Camp
□ July 30 - August 3,
2006, 10:00 am - 4:00 pm - Combined Camp (Beginning &
Intermediate Camp)
□ October 8 - 12, 2006,
10:00 am - 4:00 pm - Combined Camp (Beginning & Intermediate
Camp)
Height of Student Weight
Gender
State any health and or food problems, allergies,
Vegetarian
Date of last Tetanus Shot
Who recommended K.C. Academy to you?
Has Student had any previous riding experience?
If Yes, please check all applicable
Western Saddle English Saddle
____Bareback
Please outline riding experience (lessons, shows, etc..) Use
back of sheet if necessary for a full description.
In an emergency, if parent or legal guardian cannot be reached,
may one of the K.C. Academy Staff take student to doctor of your
choice?_______ Do you give your consent for medical treatment,
in an emergency, in the event that you or you chosen doctor
cannot be reached?______
May Student attend and participate in all activities of K.C.
Academy, on or off the property of Cedar Creek Stables?______
Has student ridden with K.C. Academy before ?_______
Please list any favorite
horses____________________________________________________
Is student bringing their own horse?_____________
Please note:
·
K.C. Riding Academy an accommodate student horses
for an additional charge of $100.00 per camp week.
Arrangements must be made prior to camp
·
A vet certificate stating that all shots are
current on the animal must be provided prior to the lesson
session starting.
Student’s
Name_____________________________________________________________________
Parent’s
Names_____________________________________________________________________
NO REFUNDS
K.C.
ACADEMY IS NOT RESPONSIBLE FOR
ANY LOST TACK OR CLOTHING OR OTHER ARTICLES
RELEASE OF LIABILITY FORMS FOR
BOTH K.C. ACADEMY
MUST BE COMPLETED PRIOR TO ENTERING PROGRAM
811 Oakmont Court
Brentwood, CA 94513
(925) 628-4071 FAX (925) 516-6840
STUDENT RELEASE FORM
Acknowledgement & Disclaimer
Students
Name______________________________________ Home
Phone_________________
Street
Address_______________________________________ Birth
Date__________________
City___________________________State______________Zip__________
Name of Parent or Legal
Guardian__________________________________________________
Street Address (if different from above)
_____________________________________________
City____________________________State________________Zip_____________
Home Phone __________________________ Work
Phone ______________________
Cell Phone ____________________________
Alternate Contact ________________________
Phone___________________ Relation____________
THE
UNDERSIGNED hereby agrees, understands and acknowledges the
following:
HORSES ARE DANGEROUS AND OFTEN UNPREDICTABLE
ANIMALS. ANY ACTIVITY UNDERTAKEN AROUND OR NEAR HORSES CAN LEAD
TO BODILY INJURY OR DEATH EVEN IF PROPER CARE IS TAKEN THE STAFF OF KC RIDING ACADEMY ARE NOT EMPLOYED FOR THE
PURPOSE OF DETERMINING WHETHER YOUR RIDING ABILITY IS SUFFICIENT
FOR YOUR HORSE, NOR IS THE STAFF OF KC RIDING ACADEMY ON THE PREMISES TO ENSURE THAT YOU
EXERCISE THE PROPER STANDARD OF
CARE AROUND THE ANIMAL.
I agree and
understand that all riding engaged in at KC Riding Academy is
solely at my own risk, and that KC Riding Academy is not liable
for any injury which may occur to me on its premises, whether
bodily injury or otherwise. I further agree to release KC Riding
Academy, its agents and employees, from any and all liability
for any injuries I may sustain while participating in any horse
related activities and agree to indemnify and hold KC Riding
Academy harmless to all claims, actions, costs and expenses,
including attorney’s fees arising there from.
The
aforesaid release and limitation of liability includes without
limitation, any obligations of KC Riding Academy with respect to
consequential damages and negligent behavior of any of its
employees. This agreement shall not be extended, altered or
varied except by written instrument signed by both KC Riding
Academy and the student (and parent where required).
I have read and understand the
foregoing ___________________________
DATE
_________________________________________
________________________________
Print Student’s
Name
Student’s Signature
IF THE ABOVE STUDENT IS A MINOR,
THE CONSENT OF A PARENT OR LEGAL GUARDIAN IS REQUIRED.
I HAVE READ AND UNDERSTAND THE FOREGOING. _____________________
DATE
_______________________________________
_________________________________
Print Parent’s or Legal
Guardian’s Name
Parent or Legal Guardian’s Signature
MEDICAL RELEASE FORM
(Must be completed for all students under 18 years of age)
Students
Name______________________________________ Home
Phone_________________
Street
Address_______________________________________ Birth
Date__________________
City___________________________State______________Zip__________
Name of Parent or Legal
Guardian__________________________________________________
Street Address (if different from above)
_____________________________________________
City____________________________State________________Zip_____________
Home Phone __________________________ Work
Phone ______________________
Cell Phone ____________________________
Alternate ________________________
Do you have any Health or Accident
Insurance______
Carrier ______________ Member
#__________________
Please list and health problems or
allergies
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
THE UNDERSIGNED PARENT OR LEGAL GUARDIAN OF
SAID STUDENT, A MINOR, HEREBY CONSENTS TO ANY X-RAY EXAMINATION,
ANESTHETIC, MEDICAL OR SURGICAL DIAGNOSIS OR TREATMENT AND
HOSPITAL SERVICE THAT MAY BE RENDERED TO SAID MINOR UNDER THE
GENERAL OR SPECIFIC INSTRUCTIONS OF ANY PHYSICIAN OR HOSPITAL.
IT IS UNDERSTOOD THAT THIS CONSENT IS GIVEN IN ADVANCE OF ANY
SPECIFIC DIAGNOSIS OR TREATMENT WHICH MAY BE REQUIRED, BUT IS
GIVEN TO ENCOURAGE THE KC RIDING ACADEMY STAFF, HOSPITAL STAFF
AND SUCH PHYSICIAN TO EXERCISE THEIR BEST JUDGMENT AS TO THE
REQUIREMENTS OF SUCH DIAGNOSIS OR TREATMENT. THE UNDERSIGNED
SHALL PAY ALL FEES FOR DOCTORS, HOSPITALS, AMBULANCES AND OTHER
MEDICAL CHARGES REASONABLE AND NECESSARILY INCURRED.
DATE_____________________
_______________________________________
_________________________________
Print Parent’s or Legal Guardian’s
Name Parent or Legal
Guardian’s Signature
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