CAMP RYMAR

PERSONAL INFORMATION

Child's Name _________________________________ Date of Birth _______________________
Parent / Guardian Name __________________________________________________________
Address ______________________________________________________________________
City / State / Zip _________________________________________________________________
Home Phone __________________________________ Work Phone _______________________
Cell Phone ____________________________________
E-mail Address _________________________________

Would you like to receive e-mail notice of upcoming events at Rymar?  Yes [   ]   No [   ]

EMERGENCY CONTACT

Name _________________________________________________________________________
Phone _________________________________________________________________________
Physician's Name ________________________________________________________________
Physician's Phone ________________________________________________________________

Does the above named child suffer from any allergies to food or medication or have existing medical
condition? Please list below:
_______________________________________________________________________________
_______________________________________________________________________________

WARNING

UNDER FLORIDA LAW, AN EQUINE ACTIVITY SPONSOR OR EQUINE
PROFESSIONAL IS NOT LIABLE FOR AN INJURY TO, OR THE DEATH
OF A PARTICIPANT IN EQUINE ACTIVITIES RESULTING FROM THE
INHERENT RISKS OF EQUINE ACTIVITIES.
(CHAPTER LAW 93-169.SEC. 91 SUB.2)

Dated This _________________ day of ________________ , 20____.

Parent or Guardian signature _________________________________

Acceptance of Equine Activity Sponsor __________________________
 

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