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If you would like to register for camp, please print, fill out, and return the following forms. Camp Registration Form Complete these 4 forms and return them along with your payment to: Eagle Creek Equestrian Center 408 Ellis Dairy Road Griffin, GA 30224 For additional info, Campers Name: ___________________________________ Campers Age: ____________ Parents Names: ___________________________________ Address: ___________________________________ ___________________________________ Home Phone: _________________________ Cell Phone/Pager: _________________________ Work Phone 1: _________________________ Work Phone 2: _________________________ Emergency Contact: __________________________________________ Relationship to Camper: ________________ Physicians Name: ____________________________________ Phone Number: ____________________________________ Allergies/Medicines/ Medical Problems: ________________________________________________________________________ **Session Dates -- Check the session the camper will attend. ____ Spring Break Camp: April 5 - April 9, 2004 ____ Summer Camp Session 1: May 31 - June 04, 2004 ____ Summer Camp Session 2: June 07 - June 11, 2004 ____ Fall Break Camp: October 11 - October 15, 2004 **Are you going to -- Check the one that applies to you. ____ Bring your own horse ____ Use a camp horse **Please read the following and check all that apply to the camper. ____ I have never been on a horse before. ____ I have ridden horses on trail rides or at fairs, circuses, etc. ____ I have ridden some on horses belonging to friends, relatives, etc. ____ I have had some lessons. ____ I have leased a horse before. ____ I owned a horse once. ____ I own a horse now. ____ I am currently taking lessons. ____ I am currently leasing a horse. ____ I participate in horse shows. I ride ___________ (English, Western, or both) **Read Carefully: WARNING Under Georgia law, an equine activity sponsor or equine professional is not liable for an injury to or death of a participant in equine activities resulting from the inherent risks of equine activities, pursuant to Chapter 12 of Title 4 of the Official Code of Georgia annotated. As a result, I, all members of my party and all of my family members, relatives, employers, and acquaintances agree to exclude Eagle Creek Equestrian Center, its owners, and its employees from any responsibility and/or liability for any injuries and/or death incurred from my participation and/or the participation of my children in any activities under the management and/or supervision of and/or on the grounds of Eagle Creek Equestrian Center. Also, I understand that my place will not be secured until payment is received; and, that slots are filled on a first-come-first-served basis. Once I have paid, fees are nonrefundable unless Eagle Creek is not able to fulfill is duties and responsibilities through the camp. Date:________________________ Signature of Responsible Party: _______________________________________ **Fees: Check all that apply to you. All fees listed are per week. Campers staying more than one week will need to adjust fees accordingly. Day Camp-------------------------------------------------------- =$250 I am bringing my own horse.-----------------------------------=$ 50 I need to purchase boots.----------------------------------------=$ 30 size: ________ I need to purchase a helmet.------------------------------------=$ 50 size: _________ I need to purchase a grooming kit.----------------------------=$ 20 **Total amount due/enclosed: $_________ ========================================================================================= Horse/Rider Photo Release _____ I, _________________________ give my permission for pictures to be taken of my (circle which one): horse name:_________ child name: _________ _____ I, _________________________ give my permission for above mentioned pictures to be displayed in the barn at Eagle Creek Equestrian Center. _____ I, _________________________ give my permission for above mentioned pictures to be displayed on the website for Eagle Creek Equestrian Center. _____ I, _________________________ do not wish for above mentioned pictures to be displayed in the barn at Eagle Creek Equestrian Center. _____ I, _________________________ do not wish for above mentioned pictures to be displayed on the website for Eagle Creek Equestrian Center. _____ I, _________________________ do not wish for pictures to be taken of my (circle which one): horse name: __________ child name: __________ _______________________________________ _______________________ Signature of Parent/Guardian/Owner Date _______________________________________ _______________________ Signature of Management/Instructor Date |
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================================================================================================================================ Liability Waiver/Release Form Riders Name: _________________________________ Parent/Guardian: _______________________________ Address: ______________________________________ ______________________________________ Phone Number: _________________________________ Additional Phone Number:_________________________ Contact Person: _________________________________ Please read carefully: WARNING Under Georgia law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in equine activities resulting from the inherent risks of equine activities, pursuant to Chapter 12 of Title 4 of the Official Code of Georgia Annotated. The term rider shall mean not only the rider, but also any minor of the rider, and also any person who uses any portion of the property, equipment, horses, and/or facilities of Eagle Creek Equestrian Center, with or without permission from Eric Beohm and/or Jessica Beohm. The rider understands that Eagle Creek Equestrian Center has made available to the rider all or a portion of the property, equipment, horses, and/or facilities of Eagle Creek Equestrian Center. But, that Eagle Creek Equestrian Center, its owners and their family, friends, relatives, and acquaintances make no warrant or claim as to the quality or character of any horse furnished to the rider. Furthermore, the rider acknowledges and understands that participation in horseback riding and/or any other activities at Eagle Creek Equestrian Center may involve substantial risk of bodily injury and/or death, as was property damage. The rider acknowledges and fully understands that the rider uses the property, equipment, horses, and/or facilities of Eagle Creek Equestrian Center at his or her own risk. As a result, the rider, all members of the riders party, and all of the riders family members, friends, relatives, acquaintances, and/or employers agree to exclude Eagle Creek Equestrian Center, its owners and any of their family, friends, relatives, and acquaintances, as well as its employees and any of their family, friends, relatives, and acquaintances from any responsibility, liability, claims, demands or other obligations, including but not limited to action at law or in equity that may arise out of or be connected with loss, injury, or damage to the rider or the riders property that may incur from participation in any and all activities under the management and/or supervision of and/or on the grounds of Eagle Creek Equestrian Center. _________________________ __________________________________ ============================================================================================================== Students Mental, Medical, and Educational History Riders Name: _____________________________________ Parent/Guardian: ___________________________________ Address: __________________________________________ __________________________________________ Phone Number: _____________________________________ Additional Phone Number:_____________________________ Contact Person: _____________________________________ *In order for Eagle Creek Equestrian Center to best serve all of its students while maintaining the highest possible standards, we need certain information regarding our students. This information is strictly confidential and will only be used by the instructor in order to plan lessons that best fit the individual students learning style. Mental and Medical History *If the rider has had or does have any of the following conditions, please check. _____ visual impairment _____ wears glasses _____ wears contacts _____ speech impairment _____ hearing impairment _____ wears hearing aid _____ reads lips _____ physical handicap Describe: ______________________________________________________ _____ heart problems _____ seizures List medications taken: ___________________________________________________ _____ asthma List medications taken: ____________________________________________________ _____ allergies List specific allergies: _____________________________________________________ List allergy medications taken: ______________________________________________ _____ back/neck conditions that affect movement Describe: _______________________________________________________________________ _____ arthritis, Carpal Tunnel Syndrome, etc. Describe: _______________________________________________________________________ _____ severe mental problems Briefly Describe: _____________________________________________ _____ emotional problems Briefly Describe: ________________________________________________ _____ phobias List: ___________________________________________________________________ _____ panic attacks _____ other Describe: __________________________________________________________________ _____________________________________________________________________________________ Educational History _____ learning disabilities Briefly describe: _________________________________________________ _____ behavior disorders _____attention problems If the rider is or was not in regular education classes at school, please explain: ______________________ _____________________________________________________________________________________ Please list any further information you feel Eagle Creek Equestrian Center and its instructors need to know in order to better serve the rider. ________________________________________________________________________________ Date ________________ Signature of Rider (or Parent/Guardian)_____________________________ |
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Phone: 770-467-1148 Email: beohme@bellsouth.net Eagle Creek Equestrian Center * 408 Ellis Dairy Road * Griffin, GA 30224 |