Parental Consent Form For:
High Peak Hunt Branch of the Pony Club
Bakewell Camp 2015
Please return ASAP to:
Charlotte Outram, Birley Cottage Farm, Cutthorpe, Chesterfield, S42 7AY
Childs Full Name: ____________________________________________
Pony’s stable Name : _________________________________________
Pony’s Age: ______________________ Height: ___________________
My Hat is tagged ________
Needs tagging _________
Emergency Contacts Numbers:
Name
Telephone
1. ________________________________________________________
2. ________________________________________________________
3. ________________________________________________________
Medical Information:
Date of Birth: ___________________________________________________
Does your child suffer from any condition about which the organisers and
instructors need to be aware ( illness/ allergy/ medical conditions) YES / NO
If yes, please provide details
Does your child take any medication?
YES / NO
Does your child use any medical equipment which needs to be kept with them
at all times e.g. Inhaler / Epipen?
If yes, please give details of medication, how it is administrated, and any side
effects:
Doctors Name ……………………………………………………………………..
Doctors Telephone number ……………………………………………………..
Doctors Address …………………………………………………………………..
……………………………………………………………………………………….
To the best of your knowledge has your child been on contact with any
contagious or infectious diseases or suffered from anything in the last four
weeks which may be contagious or infectious? YES / NO
If yes, please give details:
Is your child allergic to any medication? Yes / NO
If yes, please give details:
When did your child last have a tetanus injection? ______________________
Your Pony
Does your pony kick?
(if so it must wear a red ribbon in its tail at all times)
Vets Contact Name ______________________________________________
Vets number ___________________________________________________
Farriers Name __________________________________________________
Farriers Number ________________________________________________
In the event of emergency I agree to pony club officials contacting Bakewell
Veterinary Clinic on my behalf YES / NO
Please give any other details that we should be aware of about your pony.
I am bringing my own stable bedding ______
I will buy approx ______________ bales of Simbed @ £5.50 per bale
(cash only – purchase at camp) (you wont be held to the number of bales – I
just need a rough idea of how many to get to camp in the first place)
Double dust extracted, Highly absorbent, oil seed rape bedding.
AGREEMENTS
I have read all the information and agree to my child’s participation in the
activities described: YES / NO
I agree to my child having photographs taken whilst dressen in their pony club
attire and I understand that these photographs may be displayed on the pony
club web site: YES / NO
I agree to my child having their photograph taken as a group to appear in the
local press: YES / NO
I understand and agree that I (or another pony club parent / grandparent that
I have made a personal arrangement with and have notified PC officials on
writing) am completely responsible for my child between the hours of 1700
and 0900. I have the right to leave the camp at anytime within my
responsibility hours should I feel that my child needs time away from the camp
i.e. needs a night at home, understand that I need to notify Charlotte Outram
or Rebecca Rogers before I leave camp, and as soon as possible on my
return.
I understand that if my Child is ill during the day, I will be expected to collect
and care for them as soon as is reasonably possible.
I agree that 1 (or my nominated adult) will provide my chills with a substantial
breakfast to get them through until morning break. I understand that lunch will
be provided for my attending member by the pony club on Tuesday,
Wednesday and Thursday.
I understand that the PC officials will be responsible for giving early morning
breakfast, hay net, and water and that my participation member will, under
instruction, see to all other requirements.
PC officials will give the ponies their evening feed once they are all settled at
approx 6pm and check that they all have sufficient hay and water when the
final stable checked are made last thing.
I understand that no siblings or friends who are not PC members are allowed
in the stable field at any time
I agree to be contacted if there is an emergency with my Child or pony at
anytime and that I will keep a mobile numbers available at all times as per my
contact sheet.
I agree to tidy my pony / child’s area and remove all bedding to the muck
heap on the final day.
I agree to help with the break down of the camp before leaving with my pony.
Signed: ___________________________________________
Print: ______________________________________________
Date: ____________________________________________