2008 Summer Camp

2008 Summer Camp Registration Form Cowboy City Texas 19327 Belleau Wood Dr. Humble, TX 77338 (281)852-8452 * (281)852-4616 Fax Medical Information Health History (Give approximate dates of occurrences, mild or severe) PLEASE PRINT. Complete all information. Use N/A in areas which do not apply. Camper’s Information Name _____________________________________________ Frequent Ear Infections _________ Heart Defect / Disease _________ Address ____________________________________________ Convulsions _________ Diabetes _________ City_______________________State______ Zip____________ Bleeding / Clotting Disorder _________ Hypertension _________ Birthdate ___________________Age________Boy ___ Girl ___ Mononucleosis _________ Last Tetanus Shot _________ _Parent / Guardian Information Physical Disabilities (describe) _________ ______________________________________ Mom ________________________________________________ ______________________________________ Diseases Allergies Cell # ______________________ Other #_______________________ Chicken Pox ______ Hay Fever ______ Measles ______ Poison Ivy ______ Dad _________________________________________________ Mumps ______ Insects ______ Penicillin ______ Cell # ______________________ Other #_______________________ ADHD ______ Asthma ______ Other ____________________________ If not available in an emergency, notify: Food Allergies___________________ Name of Family Physician Name ______________________________________________ _________________________________ Phone #: ________________________ Phone #:____________________________________________ Insurance Carrier: _______________________ Policy #: _______________________________ Due to the nature of activities at Cowboy City Texas, we do not have the accommodations to facilitate campers with mental or physical disabilities. If full disclosure is not made in advance, the camp Director will be forced to refuse the camper, and the parents will be required to pick up the camper immediately. THIS FORM MUST BE SIGNED TO REGISTER. THIS HEALTH HISTORY IS CORRECT AS FAR AS I KNOW, AND THE PERSON LISTED ABOVE HAS PERMISSION TO ATTEND COWBOY CITY TEXAS, AND TO ENGAGE IN ALL CAMP ACTIVITIES EXCEPT AS NOTED. I HEREBY AUTHORIZE THE EXECUTIVE STAFF OR DESIGNATED MEDICAL PROFESSIONALS TO ADMINISTER EMERGENCY MEDICAL ASSISTANCE IF I CANNOT BE REACHED. I accept responsibility for the payment of expenses incurred as a result of medical treatment. I also release Cowboy City Texas, Mike and Mary Wall, and any staff and volunteers, from any liability person or property while my Son/ Daughter attends Summer Camp. I will be liable for any damage to the property / livestock at CCT by myself or my child. I have read the Texas Equine Laws and understand the Ranch Rules. Date:_________________Signature Mom:__________________________________________ Date:_________________Signature Dad:___________________________________________ Week # :_______________ Camp Fees: Extended Care: Deposit: Deposit: Boarding Fee: Extended Care: Yes / No Dep. Paid:____________ $295 per week $50 per week $150 $200 $50 Monday / Friday 8am-5pm 7am Drop-off 6pm Pick-up Non-Refundable paid before May 10th Non-Refundable paid after May 10th Per week / Per horse Payment Method for Camp Deposit: Cash Check Visa MC Discover AMEX Credit Card Number: ______________________________________ Amount: $_____________ Exp. Date: ____________ Signature:________________________________________________ I authorize Cowboy City Texas to process my credit card for payment of the amount listed above. You can bring your horse, tack and feed. We just need to see upon arrival, a clean original coggins. Owner will feed and clean stall. We will provide hay and water only. Horse Name:__________________________________Coggins Date:______________ Mare / Gilding / Stallion Horse Age: __________ Special Instructions: ______________________________________________________ WEEK DATES AGES PD. Reg. PD. Week * __Wk#4 July 7-11 ______ ______ __Wk#5 July 14-18 ______ ______ Photo Release: I authorize the use and reproduction by Cowboy City Texas of any and all photos and audiovisual materials taken of son, my daughter, or me for promotional, education or any other use. *I DO give consent _____ *I DO NOT give consent ____