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Camper Registration Form

Camper Information

First name*

Last name*

Birthday*

Month

Day

Year

Gender*

Address*

Weight*

Height*

Does your child have any allergies?*

Yes

No

If you selected yes, please give details:

Is your child on any medications?*

Yes

No

If you selected yes, please give details:

Does your child have any dietary restrictions?*

Yes

No

If you selected yes, please give details:

Does your child have any medical conditions?*

Yes

No

If you selected yes, please give details:

Parent information

First Name*

Last Name*

Phone Number*

Address*

Email*

Emergency Contact(s)

Emergency Contact 1

Full Name*

Relation*

Phone Number*

Emergency Contact 2

Full Name

Relation

Phone Number

Camp Sessions

Please choose the week(s) you'd like your child to attend.*

Week 1 June 13-14

Week 2 June 20-21

Week 3 June 27-28

Week 4 July 4-5

Week 5 July 11-12

Week 6 July 18-19

Week 7 July 25-26

Photo Permission

I hereby allow Lipscomb Farm permission to take photos and videos of my child and post on their social media platforms.*

I agree

I do NOT agree

Parent Permission

I certify that my child is healthy and free of problem that could be deleterious to his / her participation in the Horse Summer Camp. In case of injury, I wish to be contacted as soon as possible at the telephone number listed previous.

I also give permission to treat my child in the event of an emergency if I or the emergency contact cannot be contacted. In the event of serious illness or injury, and so that my child may be sent to local hospital via ambulance, I understand that I am responsible for all charges either through health insurance or otherwise.

I agree to terms & conditions.

Signature*

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Lipscomb Farm

(804)-489-6626

Email: LipscombFarm95@gmail.com

Facebook: Lipscomb Farm

4369 Wakema Rd, West Point, VA, USA

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