Summer Horse Camp Registration Form
Camper’s Name ____________________________________ Birth Date _______/_______/_______ Allergies_______________________________ Special Needs________________________________ Street Address______________________________________________________________________ City _________________________________ State ____________ Zip Code ___________________
Telephone (_____) ______-__________ Cell Phone (_____) ______-__________
Emergency Contact Name_____________________Relation__________
Phone (_____) ______-__________
Parent Email ___________________________________________________________________________
Persons Authorized for Drop Off and Pick Up___________________________________________
(Monday through Friday, 9am to 2pm). * early drop off / late pick up options add $10/day
_____ Session I: May 23 – 27
_____ Session II: June 6 – 10
Fee is $300 per child per session. $250 per child per session if registering for TWO or more sessions. $250 per child if siblings attending same camp.
*own horses are allowed at camp for an additional $10/day board fee during camp sessions
A non-refundable registration deposit of $50 per session is required at signup. Balance is due ON or before first day of your child’s camp session.
Please print out, complete and email or mail this registration; registration form, horseback riding questionnaire, liability release, and medical emergency information with deposit(s) to:
Second Chance Thoroughbreds
863 cotton grove rd.
Jackson TN 38305
Cash (do not mail), money order, or checks made payable to “Second Chance Thoroughbreds”
A confirmation email will be sent to you upon receipt of completed registration and deposit.
Second Chance Thoroughbreds Summer Camp
Horseback Riding Questionnaire
Please fill out this questionnaire to help us prepare for your time at camp. This form is necessary so we can match horse and rider appropriately and therefore give campers a great time at camp. Thank you!
Camper’s Name ____________________________________________ D.O.B. ___________________ Height ______________ Weight _______________
Riding Experience (check one)
____ Pre-Riding (never been on a horse, afraid of horses and/or may need support to sit balanced in saddle)
____ Beginner (ridden a horse less than 5 times, little to no experience)
____ Intermediate (taken more than 5 horseback riding lessons and performs basic riding skills)
____ Advanced (takes/has taken horseback riding lessons consistently, can walk/trot and perform basic riding skills, confident and comfortable when riding/working with horses)
Please describe any riding experience you have or anything we should know about your experience with horses. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please note, all horses and ponies are assigned by the Camp Director at their discretion. We take into consideration the age/weight/height/experience of campers to ensure a safe and enjoyable time at camp.
* please contact us if interested in bringing own horse to camp.
PHOTO CONSENT AND RELEASE
____YES! I’ll smile for the camera. Feel free to put my picture anywhere on your website, social media, printed materials or other advertising.
____No thanks. I’m camera shy! Please do not take or post pictures of me anywhere.
We’re looking forward to seeing you at camp this summer!
Second Chance Thoroughbreds
Liability Release and Agreement for this Facility and Program
(Please read carefully, and bring it pre-signed when you arrive to Second Chance Thoroughbreds, which for this agreement, is synonymous with the property located at 863 Cotton Grove RD, Jackson TN 38305)
In consideration of being permitted to ride, interact with horses and ponies, take lessons, participate in special functions, which include traveling to and from special events, clinics, trail rides, special sessions, birthday parties, pony rides, equine assisted activities, volunteering and related events and activities; I hereby:
1. Understand that horse-back riding is a high risk sport and I understand the inherent dangers of riding or being around horses and am participating at my own risk. Serious injury may result from using this facility. I am willing to accept the risk of working with/on horses.
2. Hold Second Chance Thoroughbreds and Stables; it’s owners, employees, agents, and/or volunteers harmless for any and all injuries or illness incurred by myself, my minor children and any others that accompany me on said property. I shall bring no claims, demands, actions, causes or action and/or litigation against Second Chance Thoroughbreds, Stables and/or its associates or owners as previously stated for any loss due to bodily injury or death sustained by me, my minor children, legal ward, or horse(s) in relation to the premises and operation of this facility., which includes riding, handling, or being near horses and/or other animals.
3. Understand and agree that Second Chance Thoroughbreds and Stables is not responsible for any act, occurrence, or element of nature that can scare, endanger or cause harm to a horse, causing it to react in an unsafe manner.
4. Acknowledge that I am familiar with horse riding and understand the rules governing special activities and the importance of following Second Chance Thoroughbreds Stables Rules.
5. Agree that prior to any horse related activity, I will inspect horse, equipment, facilities, etc., and if I believe anything to be unsafe or beyond my capability, I will immediately notify the person in charge and refuse to participate.
6. Acknowledge and fully understand that I will be engaged in an activity that might result in serious injury including permanent disability or death, and severe social and economic loss. Not only by my action, inaction, or negligence, but also by the action, inaction and negligence of others, the rules of the sport/activity, or conditions of the premises or equipment used. Further, I acknowledge that there may be other risks not known to me or foreseeable at this time.
7. Am aware of the risks involved with horseback riding and I assume these risks and accept personal responsibility for the damages following such injury, permanent disability or death.
8. Understand that no pets other than the animals of Second Chance Thoroughbreds will be allowed on the property.
9. Have checked with my child’s physician and my son/daughter has been given a clean bill of health to participate in horse related activities OR has specific written permission by the child’s physician and/or attending health care professional(s) to participate in horse related activities.
10. Understand that Second Chance Thoroughbreds and Stables cannot allow a person or persons to participate in any horse-related activity(s) if they have used: alcohol, controlled substances or any mood/mind altering substances. This includes illegal drugs, as well as prescription medication, if use of said medication in any way impairs a person’s alertness or perception.
11. Understand and agree that anyone using this facility and/or parent/guardian will repair or reimburse Second Chance Thoroughbreds for all expenses which include materials and time in the event of any damage to equipment, jumps, arenas, or any part of the property that is damaged by their horse(s) or themselves.
12. Am aware that inhumane treatment of the horse(s) or repeated unsafe acts will immediately void all agreements and I will forfeit any fees and rights to access this center.
13. Understand that the stable owner shall not be liable for an injury to the horse(s) or damage to any property should the said horse(s) escape from the enclosure or while on the property.
I have read this warning, waiver and release, and understand that I give up substantial rights by signing it, and knowing this I sign it freely and voluntarily agree to participate and/or have my minor children participate, knowing these risks and conditions involved and do so of my own free will.
IN CONSIDERATION for the privilege of riding, driving and/or working around horses at Second Chance Thoroughbreds the undersigned, as self, or as parent(s), or guardian(s) of the named minor, jointly or severally, do hereby agree to release, hold harmless and indemnify Second Chance Thoroughbreds, its officers, directors, trustees, agents, employees, representatives, successors and assigns from all manner of liability, loss, costs, claims, demands and damages of every kind and nature whatsoever, including but not limited to reasonable attorney’s fees, which the undersigned or said minor may now or in the future have against Second Chance Thoroughbreds, its officers, directors, trustees, agents, employees, representatives, successors and assigns, on account of any accident, damage, injury or illness, physical or mental condition, known or unknown, to the undersigned or said minor, or the treatment thereof, arising as a result of, or in any way connected to, acts or incidents occurring at or relating to Second Chance Thoroughbreds, its officers, directors trustees, agents, employees, representatives, successors or assigns, including but not limited to their negligence or gross negligence in rendering the services described above or in any way incidental thereto. I have carefully read this agreement and fully understand its contents.
Name of Participant ____________________________
Signature of Parent ____________________________. Date___________
MEDICAL EMERGENCY INFORMATION
In the event of an emergency, contact:
In the event that emergency medical aid/treatment is required due to illness or injury during center activities, or while on the property of the agency, I authorize Second Chance Thoroughbreds to:
1. Secure and maintain medical treatment and transportation if needed.
2. Release participant records upon request to the authorized individual or agency involved in the medical emergency treatment.
This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed “life saving” by the physician. This provision will only be invoked if the person(s) above is unable to be reached.
Consent Signature ___________________________________Date___________________
Parent or legal guardian, if under 18 _________________________________________
I do not give my consent for emergency medical treatment/aid in the case of illness or injury during center activities or while on the property of the agency. In the event emergency treatment/aid is required, I wish the following procedures to take place: _______________________________________________________________________________________
Consent Signature ___________________________________Date____________________________
Parent or legal guardian, if under 18 _________________________________________