DATE:                                                                      AMOUNT ENCLOSED:                            

CHILD'S NAME:                                                                                              AGE:                              

FULL ADDRESS:                                                                                                                                    

                                                                                              ZIP CODE___________________

E-MAIL ADDRESS____________________________________________

HEIGHT:                                         WEIGHT:                                  BIRTHDATE:                           

PARENT'S NAME(S):                                                                                                                         

EMERGENCY PHONE (H):                                         PHONE (W):                                         

CELL_________________

OTHER: (family member who can be reached in your absence)________________________

DOCTOR'S NAME(S):                                                                                                                        

PHONE:                                               MEDICATIONS?:                                                

INSURANCE TYPE AND POLICY NO.:                                                                                           

RIDING EXPERIENCE (CIRCLE ONE):    NONE      HAVE RIDDEN   

HAVE TAKEN LESSONS         HAVE ATTENDED CAMP                            

                                                

PLEASE DESCRIBE RIDING EXPERIENCE IN MORE DETAIL:

CIRCLE WEEK OR WEEKS IN WHICH YOU ARE ENROLLING:   (2 WEEKS MAX)

EXTENDED HOURS NEEDED?               AM                        PM                  ($5.00 HR)

Please print this form and mail it with $50 deposit to:

Fairwinds Farm
41 Tailwinds Lane
North East, MD 21901

All $50. deposits are non-             refundable.

ALL participants in the Fairwinds Summer Camp MUST send a signed waiver with their application and health history form below. Click here for a copy of the required waiver. (We MUST receive a copy of this signed waiver before we can allow your child to participate in our camp!)

CAMPER HEALTH HISTORY/

REQUIRED IMMUNIZATIONS

Physician's Name: _____________________________________ Phone Number: _____________________________________

HEALTH INFORMATION. Are there any special needs, medical conditions, or behavioral conditions that we need to be aware of to ensure that your child's camp experience is positive? Check any that apply and give more information

Explain: ___________________________________________________________________________________________

__________________________________________________________________________________________________

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