Twin Pine Farm Summer Riding Camp

Application Form

Please print and mail to the address below .

Name of Rider: _____________________________________

Age: _________  School Grade as of Sept 2011: _______

Father's Name: _____________________________________

Mother's Name: _____________________________________

Address: ___________________________________________

Home Phone: ________________________________________

Parent's Work Phone(s): ____________________________

Alternate Emergency Contact: _______________________

Relationship: ______________________________________

Phone Number: ______________________________________

Previous Riding Experience - check one:

____ No previous riding experience

____ Walk / Trot

____ Walk / Trot / Canter

____ Walk / Trot / Canter / Jumping

____ Above and has showing experience

Camp Session - check one

____ Session 1: July 11-15

____ Session 2: July 25-29

 

If there are any specific medical circumstances that we should be aware of (ie, bee-sting allergies), please comment:

Release

I give my child permission to participate in the Twin Pine Farm Summer Day Camp and accept all inherent risks and responsibility.

_________________________________   __________________
Signature of Parent or Guardian        Date

Bill my (circle one) Visa / Mastercard / Check Enclosed

Card # ______________________________________

Expiration ___________________CVC#_______________

________________________________________
Signature of card holder

Please return this form completed with the above information or with a $150.00 check to the address below.

Twin Pine Farm
34 Jewett Street
Pepperell, MA  01463