Pony Pals

Childs Name: (required)

Age:

Date of Birth

School:

Parents Name: (required)

Email: (required)

Address:

Home Phone:

Cell Phone:

Emergency Name:

Emergency Phone:

Allergies:

---YesNo

If you answered Yes, please describe the Allergy and any special instructions you may have:

Any serious illness or injuries?

---YesNo

If you answered Yes, please describe the illness or injury and any special instructions you have have:

Primary Physician's Name:

Physician Address:

Physician Phone:

Carrier:

Card #:

ID #:

Name of Cardholder:

Bay Area Equestrian Club is authorized to take photos of myself and or my child during meetings and events. (required)

I AgreeI Do Not Agree

Interested in Veterinary Medicine?

---YesNo

If you are interested in Veterinary Medicine, Please tell us about your past experiences in the Veterinary field:

Does your family own a horse?

---YesNo

At which stable do you ride?

As the Parent/Guardian, Are you interested in serving on the BAE Club Board of Directors?

---YesNo

How did you hear about BAE Club?

If you saw a flyer, where was it located?

Authorized Individuals

BAE Club staff is authorized to release my student into the care of the following people. Please provide the name, relationship to student and contact phone number for each individual.

Medical Policy (required)

I AgreeI Do Not Agree

I have read, understand and agree to the Medical Policy.

Allergy Policy (required)

YesNo

I have read, understand and agree to the Allergy Policy.

Tetanus & Rabies Waivers (required)

YesNo

I have read, understand and agree to the Tetanus and Rabies waivers.

Photo Release

I AgreeI Do Not Agree

I have read, understand and agree to the Photographic Release.

Application Agreement (required)

I AgreeI Do Not Agree

I have read, understand and agree to the Application Agreement.

E-Signature:

E-Signature Date: