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KBT CAMP REGISTRATION FORMCamper Name_______________________________________________Address_____________________________________________________City_________________________________________________________State ___________________________ Zip________________________Parents/Guardian Name_______________________________________Home Phone (________) _____________Parent/Guardian Cell Phone (________)________________________Parent/Guardian Email________________________________________Camper Birth Date: MM_________/DD_________/YY____________________Circle One: Boy / Girl Camp Date of Interest:Spring Break Half-Day Camp (12:30pm-4pm)[ ] March 13-17 Summer Full Day Camps (9am-3pm)[ ] May 29-June 2[ ] June 12-16[ ] June 26-30Summer Half-Day Camps (9am-12:30pm)[ ] June 5-9[ ] June 19-23[ ] July 17-21[ ] July 24-28[ ] July 31-August 4[ ] August 7-11List of names of family members/ friends with permission to pick-up camper:________________________________________________________________________________________________________________________________________________________________________ CONSENT AND RELEASEActivities LiabilityI request that ______________________________ [Insert name of child or participant] be allowed to participate in the one or more of the following activities: horseback riding, horse training, horse grooming, related therapeutic activities, various recreational activities, and activities related to any of the foregoing (collectively, the “Activities”), on property owned by the Terri K. Williams Living Trust, or owned and/or operated by any entity in which Terri K. Williams owns a controlling interest, together with any family members of Terri K. Williams and any members, managers, employees, officers, representatives and agents of Terri K. Williams or of her entities (collectively, “Owners”). The term “Owners” shall be deemed to include any individuals and/or entities which own real or personal property upon which, or with which, the Activities are conducted. I acknowledge that the Activities may result in: (i) physical injury, mental injury, or death, and that in any of such events there may not be adequate facilities for medical treatment or transport readily available; (ii) loss, theft, or damage to personal property; and/or (iii) damage to other persons or property caused by the undersigned or his/her child. I assume all risk and responsibility for any injury, death, or property loss or damage resulting from participation in the Activities by myself and/or my child. I release, discharge and acquit Owners, as well as all related entities and individuals, from all and each of the following: any and all claims, causes of action, damages, losses, expenses, liabilities, costs, attorney fees, and compensation of every kind or nature, whether anticipated or unanticipated, resulting from, arising out of, connected directly or indirectly with or relating in any way to the Activities, now or in the future, which may later appear or accrue, whether known or unknown. I will indemnify, defend, and hold harmless Owners from and against all and any action or claims which may be brought by or on behalf of myself and/or my child, or by other parties arising out of any injury, loss, damage, or death caused to myself, my child, my property, and/or my child’s property, regardless of the cause.I acknowledge that I have read and understood this Consent and Release, that I have had the opportunity to ask questions or clarify the terms and conditions contained herein, and that I intend to be bound by the terms of this Consent and Release.Social Media ReleaseI grant permission to Owners to capture pictures, stories, and related media materials of me and/or my participant or child (“Materials”). I authorize the use of these Materials on any and all social media platforms, including but not limited to Facebook, Instagram, Twitter, and webpages of the Owners’ choice. I release Owners from all claims and demands arising out of or in connection with any use of said “Materials”, including, without limitation, all claims for invasion of privacy, infringement of my right of publicity, defamation and any other personal and/or property rights. I acknowledge and agree that no sums whatsoever will be due to me as a result of the use of the “Materials” or any rights therein.____________________________________SignaturePlease print all information legibly:____________________________________Parent/Guardian Name____________________________________Street Address____________________________________Phone Number for Emergency Contact____________________________________CityStateZip____________________________________Email Medical Information/ Emergency Medical Consent Any difficulties with vision, hearing, or speech that staff needs to be made aware of? If so, please explain. __________________________________________________________________________ ______________________________________________________________________________________________ Any conditions limiting classroom or physical activity? If so, please explain. __________________________________________________________________________ ______________________________________________________________________________________________ Any medications or significant allergies? If so, please explain. ________________________________________________________________________________________________________________________________________________________________________ Are Immunizations Current?___________________________________________*Emergency Contacts must be reachable immediately:1.Name/Relationship to Camper_____________________________________________ Home# Day/Cell# 2.Name/Relationship to Camper_____________________________________________ Home# Day/Cell# In case of Medical Emergency Primary Care Physician’s Name & Telephone #__________________________________________________ Preferred Hospital of Choice __________________________________________________________________I acknowledge that KBT Equine does not carry medical insurance for my child and that I am solely responsible for payment for my child’s medical care. In case of medical emergency, I understand that every effort will be made to contact parents or guardians from the emergency contacts listed. In the event that these cannot be reached, I give permission for the staff of KBT Equine to hospitalize, secure proper treatment for, and/or consent to any treatment, injection, anesthesia or surgery deemed necessary for an injury or illness sustained by my child. I agree that I will not bring my child to KBT Equine while my child is ill with any communicable disease.I have read and understand all of the above information and attached policies. ____________________________________________________________________________________ Parent/Guardian Printed Name ____________________________________________________________________________________ Parent/Guardian Signature Date ................
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