2010 CAMP / WORKSHOP APPLICATION

PRINT THIS PAGE COMPLETE AND SEND TO VALERIE GARDNER 220 WAWA RD, MEDIA PA. 19063 WITH DEPOSIT.PLEASE MAKE CHECK PAYABLE TO RATTLEBOX NATURE CENTER.

NATURE/PONY CAMP AT RATTLEBOX NATURE CENTER LTD. MAY 24TH THROUGH SEPT 3RD .MONDAY THROUGH FRIDAY 10am. to 1pm. ACT QUICKLY ONLY 6-8 CHILDREN ACCEPTED PER WEEK. ONLY 2 CITS PER WEEK.
NEW CIT PROGRAM FOR 10-12 YR OLDS.
FULLY INSURED.
AVERAGE AGE OF CAMPERS IS 4-9 YEARS

NAME(S)

AGE(S)AND BIRTHDATES:

ADDRESS:

MOTHER'S NAME:

FATHER'S NAME:

PHONE NUMBERS:

HOME:

CELL:

WORK:

EMAIL:

ALLERGIES:

MEDICATIONS CURRENTLY TAKING:

CAMP RUNS FOR 13 WEEKS, COME FOR ANY # OF WEEKS.

COME BY THE WEEK. RETURN THIS FORM WITH NONREFUNDABLE CHECK FOR $250. FOR FIRST CHILD AND $225. FOR SIBLINGS. RESERVE OTHER WEEKS AND PAY FOR THEM BY WEDNESDAY THE WEEK BEFORE.
ENCLOSE $150. FOR CITS
RESERVE THIS WEEK:

(If this is for a camp day or workshop not summer camp just enclose the amount quoted and date.)

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AND ANY OTHERS:---------------------

WE ARE FLEXIBLE. TIME MISSED CAN BE MADE UP DURING THE SUMMER.
PLEASE WEAR LONG PANTS AND BOOTS TO RIDE. BRING A BIKE HELMET OR RIDING HELMET.BRING SHORTS AND SNEEKERS TO CHANGE INTO AFTER RIDING AND DON'T FORGET YOUR LUNCH!

PLEASE SEND ALONG A SNAPSHOT OF YOUR CHILD FOR OUR RECORDS!! Everyone forgets this...

RELEASE FOR RIDING
Waiver for Rattlebox Nature Center LTD

I, the undersigned, am fully aware that riding a horse is a potentially hazardous activity and I assume the risk of riding Valerie Gardner’s horses and any and all risks, such as falls, contact with other riders and horses, and the effects of uneven ground, associated with riding these horses. All such risks being known and appreciated by me as a consequence of my knowledge and understanding of the above facts, I hereby, for myself and my heirs, executors ,administrators, and anyone else who might claim on my behalf, covenant not to sue Valerie Gardner, or any of the landowners adjacent to their property in Wawa,
Pennsylvania.

Signature of parent or adult/date

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Print name of parent or adult

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Print name of child rider_(s)

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