BLACK'S HORSES & PONIES
16045
Rococo Rd. Tallahassee, FL 32309
Office/stable
(850)893-7212
www.blacksponies.com
Summer
Camp Application
Mail
in with $50.00 application fee to the address above.
Please
indicate weeks requested: _______________________________
Name:______________________________________________________________
Address:
___________________________________________________________________
Age: ___________
Height:__________ Weight:________ Grade: __________
Mother's Name:
__________________________________________________________________
Address:____________________________________________________________
Home Phone:
_____________________Business Phone:______________________
Father's Name:
__________________________________________________________________
Address:____________________________________________________________Home
Phone: _____________________Business Phone:______________________
In case of emergency
contact:___________________________________________
___________________________________________________________________
Physician's
Name:_______________________ Phone:________________________
Known
Allergies:______________________________________________________
Comments:__________________________________________________________
___________________________________________________________________
I,
___________________________________, hereby authorize BLACK' HORSES &
PONIES to secure medical services for my child _____________________________
if necessary.
____________________________________ ______________________
Signature Date
From
time to time we look for new images of our fun days at camp to display in our
barn, on our web site, in our promotional materials, and at locations of
partner companies, etc. If you prefer
that we not use any images with your child in them, just check the box next to
"No thanks, I prefer to decline. Please
don't use my images". Either way,
we hope you have a blast at camp. I know
we will!
____Yes,
you may use images of my child.
____No
thanks, please do not use images of my child.
BLACK'S HORSES & PONIES
16045
Rococo Rd. Tallahassee, FL 32309
Office/stable
(850)893-7212
www.blacksponies.com
Summer
Camp Application
Mail in with
$50.00 application fee to the address above.
Please
indicate weeks requested: _______________________________
Release
I/We
____________________________________________________________, parent(s) or
legal guardian(s) of ______________________________________ (child), by
enrolling my/our child in Black's Horses & Ponies, Inc. Summer Riding Camp,
certify that I/we are cognizant of Florida Statutes 773.04 which states as follows:
"UNDER FLORIDA 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 RISK OF EQUINE
ACTIVITIES."
BLACK'S HORSES AND PONIES,
INC. AND STAFF REQUIRE OUR SUMMER CAMPERS TO PROVIDE AND WEAR PROTECTIVE
HEADGEAR (HARD HAT) AND BOOTS 
OR SHOES
WITH A HEEL.
I/We hereby release Black's
Horses & Ponies, Inc. and any staff members affiliated with Black's Horses
& Ponies, Inc. from any responsibility for any occurrence in connection
with the Summer Riding Camp which may result in injury, death, or other damages.
I/We further state that I/we are of lawful age and competent to sign this
affirmation and release and that by signing I/we understand the terms
therein. I/We assume all responsibility
for _________________________ (child)'s physical fitness and capabilities to
perform under normal conditions of the Black's Horses & Ponies, Inc. Summer
Riding Camp.
In witness whereof I/we
have executed this affirmation and release on this _____________ day of
___________________, 20_____.
___________________________________
_______________________________________
Parent or Guardian Witness
___________________________________
_______________________________________
Parent or Guardian Witness
