Holiday Camp Registration Form

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Current Total:

$0.00

Current Total:

$0.00

Extended Care Needed @$15/hour (Available 3-5 pm. Please list times. Pay at barn on camp day.)

Rider Information

First Name *

Last Name *

Preferred Name

Age *

Date of Birth *

Height

Weight

Allergies

Restrictions

Doctor Name *

Phone *

Insurance Name *

Phone *

Member Number *

Group Number *

Riding Experience

Please select the following experience levels for each activity *

	Never	Working On	Mastered
Walk	Never	Working On	Mastered
Trot	Never	Working On	Mastered
Canter	Never	Working On	Mastered
Cross-Rails	Never	Working On	Mastered
18" Jump Course	Never	Working On	Mastered
2' Jump Course	Never	Working On	Mastered
2'6" Jump Course	Never	Working On	Mastered

Years of Riding Lessons *

Lessons Per Month *

Years of Riding Camps *

Camps Per Year *

Description of temperament *

Friends in Camp

Goals for Camp

Parent / (Spouse) Information

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Emergency Contacts

Name *

Relationship *

Phone Number *

Name

Relationship

Phone Number

Release Waivers

Liability Waiver

I have read the above Liability Waiver and agree to the terms for the child listed above and the camp dates selected. *

Yes

I give permission for my child's picture to be used for Red Gate Farm promotional material. *

Yes

I give permission for Red Gate Farm's Summer Camp program to seek medical treatment, if necessary. *

Yes

Name *

Date *

Signature *

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Enter the word in the image *
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Thurs., Oct. 3, 2024 $150, age 6+ all levels	Friday, Oct. 4, 2024 $150, age 6+ all levels
Thurs. Oct. 3- Fri. Oct. 4, $450, ride 4x, age 10+, Beg. 4+	Monday, Nov. 4, 2024 $150, age 6+ all levels
Tuesday, Nov. 5, 2024 $150, age 6+ all levels	Monday, Nov. 4- Tues. Nov. 5 $450, ride 4x, age 10+, Beg. 4+
TBD	TBD
TBD	TBD
TBD	TBD
TBD