Summer 2013
2013 PONY PALOOZA
FALL/HALLOWEEN CAMP
Welcome to 2013 Pony Palooza Camp! To register your child, please complete and sign all of the
following forms:
2013 Pony Palooza Camp Registration
2013 Medical Information Sheet
2013 Informed Consent Form
Copy of Insurance Card
Camp dates are November 1st-3rd from 4-6pm. Snacks and drinks will be provided for
campers each day, though they are welcome to do bring their own as well. Throughout the
camp, students will learn basic care for horses, have a scavenger hunt, and dress the
horses up for Halloween. Campers will also get to decorate the barn, decorate pumpkins,
ride in a mini lesson each day, and we will have a bonfire as an end of camp celebration!
Camps are limited to 8 students, ages 4 and above.
**NOTE: if the prospected campers exceeds 12 kids, we will have a second camp on the
same dates from 6-8pm.**
Cost for 2013 Pony Palooza Summer Camp is $75.00. A $25 non-refundable deposit is due at the
time of registration to reserve your spot and the rest is due one week PRIOR to the start of camp.
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Siblings are $75 for the first child and $65 for each child after that.
Payments must be made by check payable to Carrie Torre.
Completed forms may be sent to:
Carrie Torre
1296 Oakridge Road
McDonald, PA 15057
ALL FORMS MUST BE COMPLETED
AND DEPOSIT DUE BY October 1st!
Summer 2013
2013 Pony Palooza Camp Registration
Please provide the following information for Pony Palooza 2013. Please complete one form for EACH child
you are registering.
CAMPER’S NAME ________________________ DOB______ _______ Phone#________________
Address__________________________________City____________________ State ______ Zip code
________
Guardian/Mother’s Name: ______________________ Father’s Name: _________________________
Guardian/Mother’s Cell:________________________ Father’s Cell: __________________________
EMAIL ADDRESS (PRINT CAREFULLY)_________________________________________
My child rides: English ______ or Western _______
Please mark the box that best describes your child’s riding experience
◊ My child is a beginner rider, and has no experience with horses at all. He/She does not know how to
care/brush for a horse.
◊ My child is a beginner rider with walk and limited trot experience only. Just a few times on a horse. Basic
horse care only.
◊ My child rides in a lesson program, and can walk/trot with ease but needs help tacking up horse.
◊ My child rides in a weekly program, and can walk/trot/canter & care for & tack their own horse.
◊ My child can ride at walk/trot/canter and has had some basic jumping lessons. They can tack their own
horse.
2013 MEDICAL INFORMATION SHEET
Thank you for sending your child to Pony Palooza Camp. Below is a checklist for you to complete. This
information will be used in case of an accident or injury during camp. NOTE: A copy of your insurance card
is required. Please copy your card and attach it to this form to use in an emergency.
CAMPER’S NAME ________________________ Date of Birth: ___________Age _______
Please list any and all medical conditions -include mental & physical disorders treated at any time within the
past year that the staff should be aware of:
_________________________________________________________________________
_________________________________________________________________________
Approximate Date of last tetanus shot: __________
Summer 2013
◊ My child is currently taking medication(s) list all below…
Medical condition: _____________________ Medication taken: ________________
Medical condition: _____________________ Medication taken: ________________
Is your child allergic to bee stings/insect bites? □ Yes □ No
Is your child allergic to any medicines or foods? □ Yes □ No
If yes, please list allergy & reaction ______________________________________________
Is your child asthmatic? □ Yes □ No
If yes, please send inhaler with your child.
All information is kept private unless an emergency arises. This sheet will be given to the attending Doctor
in case of an emergency.
As the parents of the above child, you agree to carry medical insurance on your child. The Camp will NOT
insure riders or spectators. All medical bills will be the responsibility of the Parents of the campers.
I have read, understand, and have filled out these forms to the best of my knowledge.
Signature of Parent or Guardian: ______________________________________Date:_______________
Informed Acknowledgement of Risk Form for Pony Palooza
As a condition to my accepting to participate I hereby acknowledge that I participate at my own risk and that
I am aware that activities involving horses can be hazardous and that Pony Palooza Equine Education and
the instructors accept no responsibility or liability for any injury or loss that I might sustain as a direct or
indirect consequence of participation in any activity at camp.
I declare that I am in sound condition and undertake participation with the knowledge of the physical
demands required. I consent to receiving any medical treatment, that camp staff thinks desirable during or
after participation. I acknowledge that the safety precautions undertaken by Pony Palooza camp and staff
are a service to me and other participants but are not a guarantee of safety. I understand that horses are
unpredictable by nature, that when frightened their instincts are to jump forward or sideways, to run away
from danger, to kick, to rear up or to bite. I also understand that helmets must be worn by minors at all
times while on horseback, in accordance to the Pennsylvania Equine laws.
Signature of Parent or Guardian: ______________________________________Date:_______________
**Not affiliated with Torre Farm, LLC. **
Summer 2013
RIDERS DUTIES:
While the instructor may also inspect the riding equipment from time to time, I agree that I will be
ultimately responsible for checking my equipment, including the saddle, and if there are any problems or the
saddle becomes loose, I will tell my instructor immediately.
I agree to follow my instructor’s instructions at all times. I agree that as a condition of riding I must wear an
equestrian approved helmet (PA equine law), suitable footwear, and long pants. I agree that I will be
responsible for any injuries to horses, damages to the premises, property owned by others, injuries to any
riders or pedestrians, which I may cause by negligent, reckless or irresponsible conduct.
All minors must have a parent or guardian sign this acknowledgement and indemnity for them. By signing
below, I hereby agree to comply with all of the terms and conditions stated above.
Pony Palooza Equine Education is in compliance with Pennsylvania Equine Liability Immunity Act, P.L. 472,
No. 93 Ch 42, which states that liability for negligence shall be barred where the doctrine of knowing
voluntary assumption of risk is proven with respect to damages due to injuries or death to an adult
participant resulting from equine activities
Privacy Statement – Privacy Act 1998
By completing this form you are supplying Pony Palooza camp with personal information about yourself.
This information is needed to ensure your safety during your time with us. The information you provide will
not be supplied to any other organization or used for any other purpose that which is stated above.
I HAVE CAREFULLY READ THIS ACKNOWLEDGEMENT AND INDEMNITY. I UNDERSTAND IT, AND
VOLUNTARILY AGREE TO ALL OF ITS TERMS. I UNDERSTAND THAT THESE TERMS APPLY TO ME EVERY TIME
I PARTICIPATE AT Pony Palooza camp.
~Pony Palooza Equine Education is not affiliated with Torre Farm, LLC.~
*Initials:________________________ *Today’s Date:__________________________
*Print name of rider:
*Signature of rider:
_________________________________ _________________________________
*Print name of Parent/Guardian:
*Signature of Parent/Guardian:
_________________________________ _________________________________
Consent for*: ___riding lesson ____camp
___basic first aid by certified lifeguard if ever needed
**please check all of the above for camp**