Student's Name:

Student's Age:

Parent's Names:   Mom:___________________________  Dad:___________________________   Other:_________________________________

Work Phone:  Mom:___________________       Dad:____________________   Other:_________________________

Home Phone:________________________ Cell Phones:_______________________________________________________________________

Street

City, State, ZIP

Health Insurance
(Company and Number)

State Law requires that we have the following on file: (Give last dates of immunizations - list allergies).
 
DPT_______ MMR _______ TB_______ Polio_______Other_______

Allergies: Insect Stings_______ Asthma_______ Food_______ Other_______ None_______
 
Please use this space to supply Golden Vista with any information (Physical, medical, social, psychological, etc.) that will be of use as we work with the camper.

Doctor's Name: _______________________________ 
Doctor's Telephone: ____________________________

If my child has a medical emergency on the dates noted to the right, and I cannot be contacted then I give Golden Vista Riding Center and it's agents Medical Power of Attorney in regard to treatment of my child until such time as I am contacted. I also understand Golden Vista Equestrian Center does not provide insurance for camp.

 Parent's Signature (Required) _____________________________

Spring Break Session

March10-14

Beginners

June 2-13

Intermediate

June 16-27

Beginners

June 30- July 11

Intermediate

July 14- 25

Advanced Intermediates
(1 week intensive)

July 28-Aug 1

Beginners

 Aug 4-15

Winter Break #1 - 2008

Dec 22-26

Winter Break #2 – 2008-09

Closed Holidays

Dec 22 - Jan 2, 2009