www.caseysplace.org
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Parental Authorization and Release Form
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Registration Riding School
Parental Authorization and Release Form
Registration Free 2B Me Summer Camp
*
Indicates required field
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Date Of Birth
*
Age
*
Gender
*
Male
Female
Home Phone Number
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Other Emergency Number
*
Mom's Cellphone Number
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Dad's Cellphone Number
*
Best Email
*
Mom's Work Number
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Dad's Work Number
*
Fees
$20.00 Daily, Monday - Friday, 7:00 am - 6:30 pm
$80.00 Weekly, Monday - Friday, 7:00 am to 6:30 pm
Weekly Camp: $50 non-refundable registration fee to insure your spot.
Deposit will be applied to camp fee
Week Of:
*
Initial to approve the right to charge for late pick ups
*
Parents Initial
Initial to acknowledge that payment is due in full on the first day of week
*
Parents Initial
Methods Of Payment
We accept cash or check.
We will be closed on 4th of July for Independence Day!!
Additional Information and/or Comments
Allergies To Food
*
Allergies To Medication
*
Allergies to Laundry Detergent / Fabric Softeners / Chemicals
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Medical Conditions (If Any)
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Medications Presently Taking
*
Doctors Name
*
Doctors Phone Number
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Medical Insurance
*
Policy Number
*
Food / Drink my child LOVES
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Food / Drink my child DOES NOT LIKE
*
Hobbies or Interests
*
Does your child attend Church, if yes, where?
*
I Hereby do give/do not give permission for the following for my child
Apply / Give Benadryl as needed
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Yes
No
Apply Sunscreen as needed
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Yes
No
Authorize to treat an emergency and/or perform CPR
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Yes
No
Any other notes or concerns that we should be aware of
*
I Hereby authorize my child to be picked up ONLY by the following persons. In case of an emergency and I can not be reached, I authorize Casey's Place to contact
Name
*
Phone Number
*
Relationship
*
In Case Of
*
Pick-Up
Emergency
Name
*
Relationship
*
Phone Number
*
In Case Of
*
Pick-Up
Emergency
Name
*
Relationship
*
Phone Number
*
In Case Of
*
Pick-Up
Emergency
Required Supplies
Swimming attire-bathing suits (no bikinis). Sunblock, beach towel, water shoes or flip flops. Extra set of clothes (we will maintain clothes as needed)
Closed toed shoes are to be worn at all times on the farm unless swimming.
If you have any further questions, please feel free to contact us at 972-932-5156 or by email caseysplace2012@embarqmail.com
Submitter Signature
*
Submit
Don't forget to submit the Parental Authorization and release form!
