*********************** Quiet Place Stables *********************** Summer Riding Camp Registration Form - 2007 Last Name:________________________________ Camp Week: _____________ First Name:_______________________________ Age:______ Birth Date(D/M/Y): ____________________ Male: _____ Female: ____ Height: _________ Weight: _________ Street Address:_____________________________________________________ City:_______________________________ Province/State: ________________ Postal/Zip code:_____________ Country: _____________________________ Parents Names: ____________________________________________________ Home Phone Number:___________________________________ Work Phone Number: ___________________________________ Fax: _________________________________________________ Email Address: __________________________________________________ Health Card Number or Medical Insurance:_____________________________ Citizens other than Canadian may be required to provide a credit card if medical attention is needed. Has your camper ridden before? _____ yes _____ no If yes, where, when and at what level? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Does your camper want to ride English or Western seat? ___________________ (We like to start new riders with a Western saddle, and all new riders are taught the two handed method of riding.) What are your riding goals? ___________________________________________ What are you looking forward to doing at camp other than riding? ______________ Does your camper have any special dietary needs, ie, food allergies, vegetarian? __________________________________________________________________ __________________________________________________________________ Is transportation required to or from Ottawa or Toronto Airports for your camper? Yes_______ No_______ If yes, we will contact you with the times and cost of transportation. All campers receive a Quiet Place Stables t-shirt. Please state size: Youth Small ________ Medium __________ Large ________ Adult Small ________ Medium __________ Large ________ How did you learn of our program? ______________________________________ Would you prefer to pay the $200.00 Cdn. per week deposit by: Cheque _________ (enclosed) VISA _________ American Express ________ MasterCard ______________ E-mail transfer ____________ If you choose VISA, American Express or MasterCard, please complete the following information or call Quiet Place Camp toll free with this information. VISA/American Express/MasterCard card number: ______________________________________ Expiry date: ______________________________________ Cardholder name: ______________________________________ I would like to pay the balance of camp fees by: Cheque _________ (enclosed) VISA _________ American Express ________ MasterCard _______ If you choose VISA or MasterCard, please complete the following information or call Quiet Place Camp toll free with this information. VISA/American Express/MasterCard card number: ______________________________________ Expiry date: ______________________________________ Cardholder name: ______________________________________ Please process on March 15 ____ or May 15 ____, 2007 Please indicate order of preference of following: _____ Week 1 - July 1 to July 7 _____ Week 2 - July 8 to July 14 _____ Week 3 - July 15 to July 21 _____ Week 4 - July 22 to July 28 _____ Week 5 - July 29 to August 4 _____ Week 6 - August 5 to August 11 _____ Week 7 - August 12 to August 18 _____ Week 8 - August 19 to August 25 _____ Week 9 - August 25 to September 1 Conditions of Registration: I, the parent/guardian of the above-named participant, release Quiet Place Camp, its director, staff and agents from any loss, personal injury, accident, misfortune or damage to the above- named camper or his/her property, with the understanding that reasonable precautions shall be taken to ensure the health and safety of the above-named camper. The camp director reserves the right to dismiss a camper who, in the opinion of the director, is a hazard to the safety and rights of others or who appears to have rejected the reasonable controls of camp. No refund will be made for dismissals due to disciplinary action. Each camper must be covered by Ontario Health Insurance or equivalent medical insurance. The parent/guardian certifies that the camper is in good health, normal in condition and habits, and is amenable to camp life. By signing this form the parent/guardian is giving the camp staff the right to obtain medical attention necessary for the campers welfare and good health. The parent/guardian is responsible for all costs incurred. I hereby give permission for my son/daughter to participate in the entire program, and permission for Quiet Place Camp to act in my behalf in case of sickness or emergency. I give permission to Quiet Place Camp to use any photograph or video of my child for promotional material and that my positive statements about Quiet Place Camp may be used as testimonials in materials publicizing the camp program. I have read and understand the contents of this application, including the Cancellation Policy, Payment Policy and Conditions of Registration. This application has my approval and consent: Signed by Parent or Guardian ____________________________________ Camper ______________________________________________________ Dated the ______ day of __________________________, 2007. Please mail to: The Quiet Place Stables Summer Riding Camp General Delivery Boulter, Ontario Canada K0L 1G0