(A0006348T) www.phillipisland.ponyclubvic.org.au
ANNUAL SUMMER CAMP
3rd, 4TH AND 5TH JANUARY 2012
Ventnor Recreation Reserve Lyall St - Ventnor
MELWAYS REF. MAP 631 F3 (EDITION 35)
& Maybe some XC at 245 Berrys Beach Road -Ventnor
Dressage - Sue Spurway
Show Jumping - Shane Simpson
Cross Country - TBA
Games and Beach Activities.
Supervised Flat water Beach Ride final day.
at end Soliders Road – Coronet Bay.
Agistment available by arrangement
$200 Inclusive of meals
$85 per day 3rd & 4th of January including meals
$30 5th January - beach ride including lunch
Children 12 and under must be accompanied by a parent or guardian.
1
Riders are required to complete attached Summer Camp Application .
Enquiries: Amanda Price 0409 003 748 or Deb Morris 0407900959
Rider
Mount
Age
Flat
Grade
Jumping
Grade
Payment enclosed…$……………….cheque/cash
CONDITIONS OF ENTRY
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Entering this camp constitutes acknowledgement that PCAV rules apply and acceptance of these rules.
The organising committee reserves the right to cancel any class; divide any class; alter times; refuse any
entry with or without stating the reason.
No refunds after closing date except with vet or medical certificate.
Neither the organising committee of this camp nor the PCAV accepts any responsibility whatsoever for
any accident, damage, injury or illness to horses, riders, ground spectators or any other person or
property.
For pony club members, PCAV club member cards must be inspected at the event office before riding.
Medical armbands must be worn by all camp participants
Correct ‘standards’ numbered helmet must be worn as specified in PCAV Gear Rules. Spot checks
may occur and incorrect helmet will mean elimination.
Gear check before riding in each test/phase of the camp is required.
Queries, protests, horse abuse rules as per the PCAV Handbook of By-Laws.
Dogs must be kept on leads at all times.
Lungeing: - Lungeing at this camp must take place in the confined area designated exclusively for
lungeing, by the organizing committee.
Please Complete:
Registered Name of the Horse and /or name as officially
Entered: ___________________________________________________________________
Address of property from which the horse will be moved to the
Event: _______________________________________________________________
Address of property to where the horse will moved after the
Event: _____________________________________________________________________
Rider’s signature: ____________________________________________________________
Date: ________________________________ 2012
Guardian’s signature if under 18: ________________________________________________
Date: ________________________________ 2012
Phillip Island Pony Club Inc. No. A06348Summer Camp
Application for January 3rd, 4th and 5th January 2012
Date...............................
Family Name...........................................................
First Name................................................................
Date of Birth.............................................................
Postal Address.........................................................
E-mail........................................................................
Phone no..............................Mobile....................................
Parents/Guardians..............................................................
Other adult supporters names..........................................
................................................................................................
Riding Experience- Years............Months..................P/C
Experience.............
I................................................agree to abide by the rules, regulations,
policies, procedures and directives as stipulated by Pony Club Victoria.
I acknowledge that horse riding is dangerous and that accidents causing
death, bodily injury, disability and property damage can and do happen. I
acknowledge and agree that neither PCAV nor ‘the organisers’ shall be
under any liability for death, or bodily injury, loss or damage which may be
sustained or incurred by the applicant, as a result in participation in or
being present at PCAV endorsed events, except in regard to rights I may
have arising under Trade Practices Act 1974.
Signed......................................date.................................
Members Parent/Guardian Declaration
Must be signed for all members under the age of 18 years.
I/We consent to our above child becoming a member of the Pony Club
Association of Victoria as a member of the Phillip Island Pony Club.
I/We have read and accept the Member Declaration on behalf of our child.
Name.........................Signed.....................................date.......................
Name.........................Signed......................................date.......................
MEDICAL HISTORY FORM
The information you provide on this Medical History Form will be kept by your Pony Club in a secure place and used
only in the event of an emergency.
Personal Details
First Name: ............................................................................... Last Name: ..............................................................................
Sex: .......................................................................................... Age: .........................................................................................
Blood Group: ...........................................................................
Do you object to blood transfusions?
 Yes
 No
Have you been immunised for Tetanus
 Yes
 No
If Yes, Date: ...........................................................
Emergency Contacts
First Name........................................................................................ Last Name: .......................................................................
Phone (h) ......................................................................................... Phone (w): ........................................................................
Relationship: ................................................................................................................................................................................
First Name........................................................................................ Last Name: .......................................................................
Phone (h) ......................................................................................... Phone (w): ........................................................................
Relationship: ................................................................................................................................................................................
Health Cover Details
Medicare No.: ..................................................................................
Do you have Ambulance Cover?
 Yes
 No
Ambulance No.: .....................................................
Do you have Private Health Cover?
 Yes
 No
Fund: ......................................................................
GP & Dentist Details
Doctor: .................................................................................................................................... Phone: .......................................
Address: .......................................................................................................................................................................................
Suburb: .................................................................................................................................... Postcode: ..................................
Dentist: .................................................................................................................................... Phone: .......................................
Address: ........................................................................................................................................................................................
Suburb:..................................................................................................................................... Postcode: ..................................
Health History
Are you affected by any of the following conditions?
Epilepsy
 Yes
 No
Hepatitis (any form)
 Yes
 No
Diabetes
 Yes
 No
Blood Pressure problems
 Yes
 No
Heart Problems
 Yes
 No
Asthma/Bronchitis
 Yes
 No
Attention Deficit Disorder
 Yes
 No
Allergic reactions
 Yes
 No
Bladder/Bowel complaints
 Yes
 No
Diabetes
 Yes
 No
Hay Fever
 Yes
 No
Migraine
 Yes
 No
Nerve Disorder
 Yes
 No
Skin Complaints
 Yes
 No
Visual or hearing complaints
 Yes
 No
Other (please specify)
 Yes
 No
..............................................................................................
..............................................................................................
..............................................................................................
If Yes to any of the above, please give details of condition(s) and special requirements: ...........................................................
......................................................................................................................................................................................................
......................................................................................................................................................................................................
Regular medications stating name and dosage: ..........................................................................................................................
......................................................................................................................................................................................................
Sports injuries (please list any injury, which is current/recurring or requires surgery): ................................................................
......................................................................................................................................................................................................
............................................................................................................................................................................................wear?
Glasses:
 Yes
 No
Contact Lenses:
 Yes
 No
 Soft
 Hard
If Yes:
In the past have you ever sustained?
A fracture
 Yes
 No
If Yes, when & body part: ....................................................
A dislocation
 Yes
 No
If Yes, when & body part: ....................................................
....................................Have you ever been treated for a:
Concussion
 Yes
 No
If Yes, when: .......................................................................
............................................................................................
Head injury
 Yes
 No
If Yes, when: .......................................................................
............................................................................................
Neck injury
 Yes
 No
If Yes, when: .......................................................................
............................................................................................
I certify that the information given on this form is to be best of my knowledge a true account of my current physical
condition.
Rider Name: ............................................................................. Signature: ............................................ Date: .........................
Parent/Guardian: ...................................................................... Signature: ............................................ Date: .........................
Medical Release
Member over 18 years
If emergency medical care is required for myself and if I, or an accompanying spouse or relative, am not able to convey
permission in a timely manner, then the undersigned authorises appropriate emergency medical care as deemed necessary
by emergency medical personnel, a physician or the medical facility providing treatment.
Rider Name: ............................................................................. Signature: ............................................ Date: .........................
Member under 18 years
If emergency medical care is required for my child.......................................................................................................... and if
permission is not available in a timely manner, then the undersigned authorises appropriate emergency medical care as
deemed necessary by emergency medical personnel, a physician or the medical facility providing treatment.
Parent/Guardian: ...................................................................... Signature: ............................................ Date: .........................