Camper's Name:_________________________________________________________________

Birthdate:___________________ Age:_______ Sex: _______ Grade: ______________________

Home Address:___________________________________________________________________

City:_______________________ State:________ Zip:_______ Home Phone:_________________

How did you hear about River Edge Farm? _____________________________________________

School camper attends:__________________ Other camps attended by camper:______________

The following information is very important for River Edge Farm to have in the event of an emergency.

*Applicant lives with: both natural parents single parent father/step-mother mother/step-father grandparents other If parents are divorced, who has legal custody? ____________________________________
Who should be contacted during camp? ______________________________

PARTICIPANT AGREEMENT/TERMS AND CONDITIONS

1. All participants will agree to abide by all River Edge Farm LLC rules and policies.

2. Director may dismiss a participant from River Edge Farm Day Camp at any time.

3. River Edge Farm is NOT responsible for any lost articles of clothing or campers' personal articles.

4. River Edge Farm may use photographs/video of participants for promotion.

5. Campers in all camp programs must be present at camp each day of the first week of each session they attend.

6. Emergency Release: If participant is a minor, the undersigned parent/guardian agrees that in case of an emergency at River Edge Farm involving their child, if they are unable to be contacted, the parent/guardian gives permission for staff personnel present to contact the doctor listed or alternative doctor and permit whatever treatment is deemed necessary by the doctor for the emergency.

7. Cancellation policy - Deposits and camp fees are non-refundable for any reason.
Our expenses are fixed in advance therefore there will be no deductions taken for entering late or leaving early.
In the event that a camper cannot attend any session for medical reasons, or a family emergency a credit for the unused portion of their session will be granted to be used toward their tuition the following year or will be applied to riding lesson package.

Our camps take place in the outdoors and include activities which are adventurous and challenging. All camp activities contain certain inherent risks. Our purpose for this disclosure is not to cause you undo concern but to inform you of the risks connected with the fun, adventure and challenge of all camp programs.

8. Assumption of Risk and Hold Harmless Agreement.
You as parent/guardian of your child(ren) are aware of the inherent risks of injury, death and property damage involved in camp activities including but not limited to horseback riding,etc.
You as parent/guardian shall indemnify, defend and hold harmless River Edge Farm Day Camp
and its employees, agents, owners of property used/leased by River Edge Farm and representatives (collectively) against all liability demands, claims, costs, losses, damages, recoveries, settlements incurred by indemnities ("losses") regardless of cause other than gross negligence, known or unknown, arising from your child(ren)'s participation in River Edge Farm Day Camp activities.

PARENT/GUARDIAN SIGNATURE _______________________________DATE ______________

The following information will greatly assist River Edge Farm in determining a camper's readiness for the camp programs.
Camper's Name ____________________________________________________________________

STATEMENT OF CAMPER'S HEALTH HISTORY AND WELL BEING
(Note: Campers attending programs 2 weeks or longer must complete a health form signed by a licensed physician)

Doctor's Name ____________________________________________________________________

Phone (___) ______________ Fax (__)___________

Is the camper in good health and able to participate in all camp activities?
Yes. No.

Restrictions:______________________________________________________________________

Is the camper receiving medical treatment or under the care of a psychologist/therapist/physician?
Yes. No. If yes, why? ____________________________________________________________

Is the camper currently enrolled in a special school/class?
Yes. No. If yes, why?
________________________________________________________________________________

Does the participant currently take medication?
Yes. No. If yes, what and why?
________________________________________________________________________________

Will the camper be taking medication at camp?
Yes No (if Yes, we will send you a "Request for Giving Medication at Camp" form)

Health History: Check giving approximate dates

Immunizations
DPT
Tetanus
Polio
Measles

Allergies:
_________________________________________________________________________________

Special Needs:
_________________________________________________________________________________

Details or information we should know about your child:
_________________________________________________________________________________

*If a camper has a known complicating medical problem or has had an operation or serious illness since the last health examination, camper must have written permission from a licensed physician in order to participate in the camp program.
Please notify the camp if the participant is exposed to any communicable disease.

ADDITIONAL CAMPER INFORMATION
In general terms how has your child's school year been?

What would you as a parent like your child to gain from camp?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

What would your child especially like to do as a camper at River Edge Farm?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________