WPC GI7!wHI7tQv`|!wHV \P|CD,Ob/2*5Vۇ \ j T%Tm?#xGҠlqk?;p* MȽ_׷O0*HGShaiƞk7Y~hS܇ZRJ`s+8r;֢%Ea/w 'ݍ:: ;yGc kا3dC|Ơg$N1X'[ UkÇ _Chvպ/آ2]^vnXb0/j^.:`\wFmFzKqF]9 u]|a& ՏRG9V[N .rDӰL՝a&a&08Ku}w%+wЯ$[Omm"ʇ+ApIAq6de.qh-f#U"N] % 0: ^ w 4   m UN7 U 4  U@ 0c 1ur 72 0w 0 0 0 0n 05 0 0D 1oC 72k 0VO D5 B ASJ 0V 0DfHP psc 1600 seriesRR0(9 Z6Times New Roman RegularX($USUS.,*: :ntFold3|xU4-AZ6Sneakerhead BTN Shadow 'P$ ZRomana BT    (9 Z(Times New Roman (;3$2#  0  .3  0  3#37=CIQYag1.a.i.(1)(a)(i)1)a)i)(Oo$0  2#  a  .3  0` (bYX$0  0` 2#   .3  0 ` ` (x$0  0` 0 ` ` 2#(  0  )3  0  (d$0  0` 0 ` ` 0  2#(  a  )3  0h(G$0  0` 0 ` ` 0  0h2#(   )3  0hh($0  0` 0 ` ` 0  0h0hh2#  0  )3  0(/$0  0` 0 ` ` 0  0h0hh02#  a  )3  0p(=;$0  0` 0 ` ` 0  0h0hh00p2#     )3  0pp y3GKOSW[_cCheck Box&&&&&&&&& a d"USUS.,  _ XXOFFICEUSEONLY   (y3"3"  32&3  0 X   Confirmationofdates3/݌XX Ќ  "3"  32&3  0 X   Copyofmedicalcard3݌``XX Ќ  "3"  32&3  0 X   Depositcheckof$80.00(pdck#_),BalanceofCamp$____________(pdck#)3݌XX Ќ  "3"  32&3  0 X   Signaturesontermsandconditionandreleases(.3$ !USUS.,  YYYY)!dxdx dcdWeXE<<CLevel 1Level 2Level 3Level 4Level 5(.3$ !USUS.,  ($$   1  !USUS.,  _ ,    XUXXX _ RKQX XUTERMS,CONDITIONS,MEDICALRELEASEANDAPPLICATION# XUXQ RK##X8XX XU#  ,    Xw@XXX8 TERMSANDCONDITIONS #X8XX Xw@{#. b    XX8Horsesports,farmanimals,farmequipment,lessonsandequipmentcouldbedangerous.Priortostartofdaycampallparticipants T parentswillberequiredtosignthe_FSEC_sAssumptionofRisk,ReleaseAgreement._FSEC_Ԁreservestherighttorefuseserviceorterminate D acampparticipantatanytimepriororduringcamp.    Ifthereisasituationthatpreventsdaycampfromcontinuingorifacampparticipantisdismissedby_FSEC_Ԁaproratedrefundwill  begiven.Allrefundsaretobeproratedminustheinitialnonrefundable$80.00forsuppliespercampparticipant. d   _FSEC_Ԁhastherighttosubstituteoromitwithoutnoticeanyofthespecialityactivitieswiththeexceptionofhorsebackridinglessons.#X8X # T( DaycampdatesavailableareJuly7th,2009throughAugust21st,2009.    Daycampisfor3hoursfrom11amto2pm    Lunchandsnacksareprovideddaily   Horsebackridinglessonsfrom11:00amto12:30pm   Lunchfrom12:30pmto1:00pm   Specializedactivitiesfrom1:00pmto2:00pm   Withpriornoticethereisanoptional1hourearlydropoffat10:00amforanadditional$12.00perdayandonehour ` latepickupaftercampforanadditional$12.00perdayforpickupat3:00pm. xL  Xw@XXX8 PRICINGANDOPTIONOFDATES. #X8XX Xw@# P$ #1)2daysperweekforfourweek=8lessons@$380.00(nonrefundable$80.00forsuppliesincludedinprice) B #2)4daysperweekfortwoweeks=8lessons@$380.00(nonrefundable$80.00forsuppliesincludedinprice) . #3)4daysperweekforfourweeks=16lessons@$660.00(nonrefundable$80.00forsuppliesX8XXX8included#X8XXX8 #inprice)  Pleasemarkyourchoiceofoption#________,  sb?/+b~G^ `@E%^ttp=ms &%&%%% %%&%&%PrivateEnglishorWesternhorsebackridinglessonsandminicartlessonsareavailablefor$35.00perhour. f:  Xw@XXX8 APPLICATION #X8XX Xw@ #. >! MothersName____________________________________Emergency#_________________________________ 0 " FathersName_____________________________________Emergency#_________________________________ " $ PARTICIPANTSNAME_________________________________________AGE_________GENDER_________ #"& Address______________________________________________________________________________________ %$( ____________________________________________________________________________________________ 'd&* Home#_________________________Fax#______________________email_____________________________ h)<(, Doesyourchildhaveanyhealth,medicalorphysicalrestrictions?_________________________________________ @+*. _____________________________________________________________________________________________ ,,+/  XX8  (ifsowillneedareleasefrommedicaldoctortoparticipate)#X8X # -+0 Page1of2 /.3  _      Doesyourchildtakeanyprescriptionmedications?____________________________________________________ , ____________________________________________________________________________________________   XX8  (ifsowillneedareleasefrommedicaldoctortoparticipate)#X8X #    Doesyourchildhaveanyfoodrestrictions(soda,nuts,jelly,or?)__________________________________________  ____________________________________________________________________________________________ t    XX8   (Pleaselistfoodrestrictionsindetail)#  n# `   X8X  Doesyourchildhaveanyallergies?________________________________________________________________ < _____________________________________________________________________________________________ (   Doesyourchildhavespecialemotionalneeds?_______________________________________________________   ____________________________________________________________________________________________   Whatisyourmedicalinsurancecarrierforyourchild__________________________________________________   Nameofchildsphysician___________________________________________Phone#______________________ p InformationneededtoprovidemedicalproviderSS#s_________________________,________________________ tH    r    "  z    *      2  XX8(Parents)#X8X # `4 Employer___________________________________________,________________________________________ L   Xw@XXX8  X Xw@PARENTSAUTHORIZE_FSEC_Ԁ/_Lia_Ԁ_Coulombe_Ԁ/ANDHOSPITALTOMAKEMEDICALDECISION #  #   FORPARTICIPATINGCHILD# Xw@X # &])%X Xw@ #&%% &])# $   #X8X%&l# XX8Ifyourchildseamstobeseriouslyinjuredwhileat_FSEC_Ԁthefiredepartmentwillbecalledandthenemergency#sprovidedby  parentswillbecalled.OnceexaminedbyfiredepartmentsEMT,andiftheydeterminethatyourchildshouldbetakentothehospital_FSEC_  willsendsomeonewithambulanceuntilparentscanarrive.IfEMTfeelsyourchildismedicallyfit_FSEC_Ԁwillwaitforparentsdecisiontoleave tH childforremainderofcamporpickupchildearly. 8  Bysigningbelow________________________________________,____________________________________________    (parents)  Aparentsof_______________________________________________________give_FSEC_Ԁ/_Lia_Ԁ_Coulombe_Ԁsoleauthorizationtocallmedical X servicespriortocontactingparentsandifparentscannotbereachedparentsgive_FSEC_Ԁ/_Lia_Ԁ_Coulombe_Ԁauthorizationtomakesoledecision H ifchildneedshospitalization.Parentshaveprovidedacopymedicalinsurancecardthatistobeusedformedicalservicesprovidedforchild.    (ATTACHCOPYOFCARD)! HenryMayoHospitalistheclosesthospitalto_FSEC_Ԁandchildwillmostlikelybetakento_HMH_ԀinSanta   _Clarita_Ԁunlessotherwisestipulatedhere(______________________________________________________)byparent.c"ԀIfparentscannotbe j! reached,parentgivesprovidinghospitalauthorizationtoprovidemedicalprocedurenecessarytostabilizeparticipatingchildconditionuntil Z." parentscanbereached.#X8X ## #  X8XXX8 Bysigningbelowparentshaveread,understoodandagreewithtermsandconditions,pricingandoptions,medical  % release,conductforparticipant,andattachedassumptionofrisk,andreleaseagreement.  ! & Motherssignature____________________________________________date__________________________#X8XXX8%# Xw@XXX8 #f"( #X8XX Xw@&#X8XXX8Fatherssignature_____________________________________________date#X8XXX8'# Xw@XXX8__ p%D$* CONDUCT#X8XX Xw@'# Xw@XXX8ԀOFPARTICIPANT#X8XX Xw@%(#  T'(&,  XX8Ipledgenotuseprofanity,treatotherparticipantswithfairnessandkindness,payattentionandfollowinstructorsinstructiontoinsuremy F('- safety,treatanimalswithkindness,wearappropriateclothingtocamp,workonanyprojectssenttofinishathome,helpmyparentsathome,  )'. bekindtomybrothersandsisters,helpotherparticipants,andmostofallhavefunatcamp.I )(/ ______________________________________________pledgetodomybestfollowtheabovelistofconduct. *f)0 ______________________________________________#X8X (# ,*2  XX8(ParticipantsSignature)#X8X L+# ,+3 Page2of2  XUXXX8 ]X XUTERMS,CONDITIONS,MEDICALRELEASEANDAPPLICATION# XUX ] ,# #X8XX XU+# .b-5  z/N.6