NAME OF CAMPER_______________________________________ AGE ________
Birth Date(M/D/Y): ____________________ Male: _____ Female: ____ Height: _________ Weight: _________
Street Address:______________________________
City:_______________________________
Province/State: ________________
Postal/Zip code:_____________
Country: ________________
I want to attend:
- Before & After School Academy, begins Sept. 3, 2008 ($130/wk):_______
- Winter Break Camp 2008, Dec. 29- Jan. 2nd 2008, 8am-3pm ($400/week):________
- Week Long Overnight Session (Sunday 4pm-Saturday 1 pm, $610.00):________
- Autumn Twilight Camp Sept. 20, 2008 4-7pm($35):______
- Autumn Twilight Camp on Oct.17, 2008 4-7pm($35):______
- Harvest & Horses Day Camp on Oct. 3rd, 2008, 8:00am-5:00pm ($80.00):_________
- Harvest & Horses Day Camp on Nov. 11th, 2008, 8:00am-5:00pm ($80.00):_________
- Saddle Club Session, start anytime ($120.00):_______
If attending Day Camp, please indicate which dates you would like to attend:_____________________
Overnight Camper Info:
Parents Names:______________________________Home Phone Number:__________________________
Cell Phone Number: ______________________
Work Phone Number: __________________
Fax: ________________________
Email Address: _______________________Please print email address carefully. Before camp begins, we email camp information including a packing list, directions to camp, room mate information, etc. WE FEEL THE SAME WAY YOU DO ABOUT SPAM AND UNWANTED EMAILS. WE NEVER SELL OR SHARE YOUR INFORMATION. NOR DO WE SEND OUT MASS MAILINGS. WE WILL ONLY USE YOUR EMAIL TO SEND YOU INFORMATION REGARDING YOUR CAMPER ONLY.
Health Card Number or Medical Insurance:_______________________
Citizens other than American may be required to provide a credit card if medical attention is needed.
Has your camper ridden before? _____ yes _____ no
If yes, where, when and at what level? Please be clear and honest. _____________________________________________________________________________________________________________ __________________________________________________________________ __________________________________________________________________Does your camper want to ride English or Western seat? ___________________
This is only to help us determine general interest in each discipline. Every camper has the option of choosing a different discipline EACH DAY OF CAMP, REGARDLESS OF WHAT YOU STATE HERE.
What are your riding goals? ___________________________________________
What are you looking forward to doing at camp other than riding? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________Does the camper have any emotional, behavioral, physical, dietary, allergic or other conditions of which we should be aware? _______________________________________________________________________________________________________________________________________________________________
Is transportation required to or from Seatac Airport for your camper? Yes____ No____If yes, we will contact you with the times and cost of transportation.
Please state size if ordering or if you are a week long camper (shirts run a little small):
Youth Small ________ Y Medium __________ Y Large ________
Adult Small ________ A Medium _______ A Large ________
Enclose a check for appropriate amount if you are not a week long camper and you want a t-shirt.
How did you learn of our program? ______________________________________
If online, which search engine/ search words______________
If school flyer, which School District_______________(thank you!)
I have paid my (check one) _____deposit ______ full tuition via paypal using the name _____________________________________ on _______________(date).
I would like to pay the balance of camp fees by:
- Check _________
- VISA______
- MasterCard _______
VERY IMPORTANT!! IF, WHEN YOU PRINT THIS OUT, THE RELEASE FORM IS NOT ALL ON ONE PAGE, A PARENT OR GUARDIAN MUST SIGN AND DATE EACH INDIVIDUAL PAGE THAT THE RELEASE PRINTS ON. THANK YOU.Release executed on the ____ day of _______, 20___by _____________________( the ‘Releasor’) and minor child_______________________ of (Address) _________________________, (City)_______________(State)_____ (County)____________, to Chastain Mist and Company, and all agents . Conditions of Registration: I, the parent/guardian of the above-named participant, release Chastain Mist Summer Camp, Chastain Mist and Co., its director, staff and agents from any loss, personal injury, accident, misfortune or damage to the above- named camper or his/her property, with the understanding that reasonable precautions shall be taken to ensure the health and safety of the above-named camper. The camp director reserves the right to dismiss a camper who, in the opinion of the director, is a hazard to the safety and rights of others or who appears to have rejected the reasonable controls of camp. No refund will be made for dismissals due to disciplinary action. Each camper must be covered by medical insurance. The parent/guardian certifies that the camper is in good health, normal in condition and habits, and is amenable to camp life. By signing this form the parent/guardian is giving the camp staff the right to obtain medical attention necessary for the campers welfare and good health. The parent/guardian is responsible for all costs incurred. I hereby give permission for my son/daughter to participate in the entire program, and permission for Chastain Mist Summer Camp to act in my behalf in case of sickness or emergency. I give permission to Chastain Mist Summer Camp to use any photograph or video of my child for promotional material and that my positive statements about Chastain Mist Summer Camp may be used as testimonials in materials publicizing the camp program.
I, The Releasor, in consideration of my minor son or daughter or self being permitted to participate in any Chastain Mist and Company program, including but not limited to riding Lessons, riding camp, horse boarding, field trips, trail rides, run and/or operated by the Releasee, WAIVE, RELEASE, and DISCHARGE the Releasee, his/her heirs, executors, administrators, legal representatives and assigns from all liability for or by reason of any damage, loss, or injury to person and property, even injury resulting in death of myself or above named minor child, which has been or may be sustained in consequence of the Releasor’s participation or the participation of the Releasor’s child in the activity described about, and notwithstanding that such damage, loss or injury may have been caused solely or partly by the negligence of the Releasee.
I hereby acknowledge and agree that I have carefully read this Waiver and Release agreement, that I full understand same, and that I am freely and voluntarily executing same.
By signing this release I will be forever prevented from suing or otherwise claiming against the Releasee for any property loss or personal injury that I may sustain while participating in or preparing for the above noted activity.
I have been given the opportunity and have been encouraged to seek independent legal advice prior to signing this Waiver and Release agreement.
I understand that this Waiver and Release agreement is binding on me, my spouse, my heirs, my executors, administrators, personal representatives and assigns.
I acknowledge that I do not have nor does my minor child have any physical limitations, medical ailments, physical or mental disabilities that would limit or prevent me from participating in the above mentioned activity.
This release contains the entire agreement between the parties to this release and the terms of this release are contractual and not a mere recital.
This Waiver and Release Agreement will be construed in accordance with and governed by the laws of the State of WASHINGTON, and it is acknowledged by the Releasor to be as broad and inclusive as permitted by the laws of this jurisdiction.
Check this box if your child can participate in all activities, including traveling to and swimming at Long Lake Park with Chastain Mist Summer Riding Camp. If box is not checked, child does not have permission to participate.
I HAVE READ AND UNDERSTAND THIS AGREEMENT, AND I AM AWARE THAT BY SIGNING THIS AGREEMENT I AM WAIVING CERTAIN LEGAL RIGHTS WHICH I OR MY HEIRS, NEXT OF KIN, EXECUTORS, ADMINISTRATORS AND ASSIGNS MAY HAVE AGAINST THE RELEASEE(S).
I have read and understand the contents of this application, including the Cancelation Policy, Payment Policy and Conditions of Registration. This application has my approval and consent:
The Releasor has executed this Waiver and Release at (City)______________,_______________(County), WA on the _____day of __________, 20___. Signature of Releasor ___________________________________
Signature of Camper _____________________________________
Please make checks payable to CHASTAIN MIST
and mail to:
Chastain Mist Summer Camp
P.O. Box 3262
Lacey, WA 98509
OR FAX TO (360) 236-1825
If you choose to fax, your spot at camp will not be officially secure until we receive a deposit via paypal or a check/money order/cashiers check via mail.
After we have received your registration, we will call or email to confirm.