New York Admissions

Success at camp is possible only with the accurate provision of information and close cooperation of the parent, information provided must be accurately completed. Any false or misleading information is grounds for immediate dismissal of the student from the Pre-Vet Program.

New York

Name (*)

Email (*)

Phone Number (*)

Street Address (*)

City (*)

State (*)

Zip Code (*)

First Name (*)

Last Name (*)

Birthdate (*)

Gender:

MaleFemale

School (*)

Emergency Contact Name (*)

Relationship to Student (*)

Emergency Contact Phone (*)

I __________(parent/guardian) authorize any medical provider to release confidential medical information to any BAEVC staff member relating to the emergency medical treatment of my son/daughter ____________(name of student) I do so as the authorized legal guardian of the minor _______________(name of student)
I ________(parent/guardian) authorize BAEVC to contact my students health care providers

Physician's Name: (*)

Physician's Phone: (*)

Insurance Carrier: (*)

Insurance Contact #: (*)

Insurance Policy #: (*)

Physical/Cognitive special needs or challenges? (*)

N/A if none.

Activities limited by physician? (*)

Any allergies, including food? (*)

Asthma? (*)

---YesNo

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

Does your student use an EpiPen? (*)
---YesNo

Does your student use an asthma inhaler? (*)

---YesNo

Currently taking medication? (*)

---YesNo

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

How did you hear about Vet Camp?

Where did you see a Vet Camp flyer? Please share city and location.

Mental, Emotional, and Social Health

Has your student ever been diagnosed with any of the following Mental, Emotional, and/or Social Health disorders? (*)

Asperger's SyndromeAttention Deficit Disorder (Add or AD/HD)AutismBehavioral or Disruptive DisorderBipolar or Mood DisorderDepressionDisordered EatingLearning DisabilityObsessive-Compulsive DisorderOther Mental, Emotional, or Social Health ConditionPanic, Anxiety DisorderSensory Processing DisorderSubstance AbuseNone of the above

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

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 Equine Vet Camp, LLC., 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.

YesNo

Welcome Packet (*)

I AgreeI Do Not Agree

I have read, understand and agree to the Welcome Packet.

Medical Policy (*)

I AgreeI Do Not Agree

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

Allergy Policy (*)

YesNo

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

Tetanus & Rabies Waivers (*)

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 (*)

I AgreeI Do Not Agree

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

Student Testimonial Waiver (*)

I AgreeI Do Not Agree

I have read, understand and agree to the Student Testimonial Waiver.

Waiver of Liability, Assumption of Risk & Indemnity Agreement (*)

I AgreeI Do Not Agree

I have read, understand and agree to the Waiver of Liability, Assumption of Risk & Indemnity Agreement
You may wish to save the contents of this page for your personal records, as a formal copy will not be given.
Electronic Communications You have authorized [BAEVC] to communicate with you via e-mail and other electronic means such as by fax. You acknowledge that communication by electronic means is subject to interception by others, as are mail and other forms of communication. By authorizing us to communicate with you via electronic means, you are assuming any risks associated therewith. ….. By signing this [BAEVC Policies Document Agreement], [STUDENT] and [BAEVC] each acknowledge that such party has read, understood and agreed to the terms hereof, and that this document contains the entire agreement between [STUDENT, his or her legal guardian] and [BAEVC] with respect to the services to be provided to [STUDENT] by [BAEVC]. Assent by Electronic Means or Electronic Signature This clause is both a recital and an agreed upon term of the [BAEVC Policies Document Agreement]. The parties agree that they may be bound to the terms set forth in this [BAEVC Policies Document Agreement] through either physical or electronic signatures and that this agreement may be entered into by electronic means. By affixing an electronic signature to this document and transmitting it to [BAEVC], you agree and represent that said electronic signature signifies assent to the terms of this [BAEVC Policies Document Agreement] and that said signature satisfies the requirements of both California law (including the Uniform Electronic Transactions Act, Civil Code section 1633.2(h), 1633.5, and 1633.7) as well as the Federal Electronic Signatures in Global and National Commerce Act (sometimes known as E-Sign). You further represent and agree that if you are a governmental agency and are employing an electronic signature, that signature complies with Government Code section 16.5 and any other laws or regulations relating to the validity of the signature and the entity’s authority to enter into this agreement by electronic means.

E-Signature: (*)

E-Signature Date: (*)