Central Arizona Riding Academy 2008 Summer Program Application
Name___________________________________________________________________________
Street Address___________________________________________________________________
City___________________________State_______________________________Zip___________
Age_____________________ Date of Birth:___________________________________
Riding Ability: ________________________________________________________________________________________________________________________________________________________________________
If Currently Taking Lessons please tell us where and for how long:______________________________________________________________________________________________________________________________________________________________
Allergies: _______________________________________________________________________________
Any Medical Conditions we should know about? ______________________________________________________________________________________________________________________________________________________________
All students are required to have a current tetanus shot. Please tell us the date of immunization:__________
Permission to swim: There MAY be the opportunity to swim at the YMCApool ___ Yes ___ No
Contact information:
Parent or Guardian’s Name______________________________ Home Phone:__________________
Work Phone__________________________Cell Phone______________________________
Emergency Contact Name______________________ Relationship___________ Phone:____________
Emergency Contact Name______________________ Relationship___________ Phone:____________
. I give permission for my child to attend any and all field trips ___ Yes ___ No If no I, understand that I will need to sign a separate release for each field trip. If possible, we appreciate parent drivers.
I, the Undersigned, agree to hold harmless Ulrich Schmitz, individually, Dorie Vlatten-Schmitz, individually, d/b/a Central Arizona Riding Academy, Inc., having it’s usual place of business at 41655 N. Kenworthy RD Queen Creek AZ 85240 , and their successors in title, employees, and volunteer helpers free from any and all claims and demands of any nature that may be occasioned by me, my guests, minors in my charge, or my horse's), and to repay on demand any and all damages, Central Arizona Riding Academy, Inc. or any individuals described above may sustain by reason of any such claim.
I, the Undersigned, agree in the event of any emergency to the above named minor or myself, or an equine to accept emergency medical care and hereby release Central Az. Riding Academy and the individuals described above from any claims for liability for loss of use to my person or property.
I, the Undersigned, will abide by the rules and accept decisions rendered by the Owners and/or Operators of Central Az. Riding Academy including all persons described above.
Date:_____________________________ Signature:_____________________________________
(If participant is a minor, parent or legal guardian must sign)
Participant Health Insurer:__________________________________________________________
Policy number:___________________________________ Telephone Number: ______________
