Student Information

Student Name

Student Age:

Student Grade in 2015
---1st2nd3rd4th5th6th7th8th9th10th11th12thCollege FreshmanCollege SophomoreCollege JuniorCollege Senior

Name:

Relationship to Student:

E-Mail

Work or Cell Phone:

Home Phone:

Occupation:

Employer:

Do all parents in the student’s family work outside of the home?

If a parent is not currently employed, please explain:

Is there financial support for the student from sources other than parent (s) or guardian(s)?

Please be specific about amounts of such support:

Please specify how much you can contribute toward the cost of BAE Vet Camp:

Please describe details pertaining to your particular financial situation using the space below, or attach supplemental letter that addresses any recent changes in your Family’s situation or circumstances that affect your ability to pay the full cost of BAE Vet Camp.

E-Signature (If Under 18, Parent/guardian):

E-Signature Date:

First Name (required)

Last Name (required)

Email (required)

Phone Number (required)

Street Address

City

State

Zip Code

First Name (required)

Last Name (required)

Birthdate (required)

Grade in Fall 2015 (required)

School (required)

Commuter, $2,000Commuter (Returning Student & Siblings - $50 Discount) $1,950**Commuter (Early Registration Ends March 31, 2015 - 5% Discount) $1,900Residential, $3,000Residential (Returning Student & Siblings - $50 Discount) $2,950**Residential (Early Registration Ends March 31, 2015 - 5% Discount) $2,900

**Combine with Early Registration for more savings!

Emergency Contact Name (required)

Relationship to Student (required)

Emergency Contact Phone (required)

Physician's Name

Physician's Phone

Insurance Carrier

Physical/Cognitive special needs or challenges? (required)

N/A if none.

Activities limited by physician? (required)

Any allergies, including food? (required)

Asthma? (required)

---YesNo

If yes to any of the above, please give us additional details and instruction.

Does you/your student use an EpiPen? (required)
---YesNo

Does you/your student use an asthma inhaler? (required)

---YesNo

Currently taking medication?

---YesNo

If yes to any of the above, please give us additional details and instruction.

Anything we need to know to ensure the safety of you/your student? (ex. custodial issues, phobias, etc.)?

Anything we need to ensure the most enjoyable experience for you/your student?

Riding Level:

---BeginnerIntermediateAdvanced

Riding Style:

Interested in Veterinary Medicine?

---YesNo

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

T-Shirt Size:

---Youth SmallYouth MediumYouth LargeYouth XLSmallMediumLargeXL

Do you own a horse?

---YesNo

At which stable do you ride?

Interested in joining BAE Club?

---YesNo

How did you hear about us?

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.

My student has my permission to accompany Bay Area Equestrian Club, its camp counselors, mentors and its agents on all club sponsored field trips during camp. I understand that I will be notified in advance of any special instructions. Unless otherwise notified, students are to wear the BAECamp t-shirt on all field trips.

YesNo

Swimming:

My student is a swimmer:

---YesNo

Permission to swim:

---YesNo

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: