Equine Vet Camp Registration

UC Davis Exclusive Workshop Registration

Registration Options - Choose One (1). Payment due upon completion of application.

*Note: The UC Davis Workshop is included with Camp tuition. This 1-day event is also open to students and adults that are not attending camp!


Parent/Guardian Information

First Name*

Last Name*)

Email*)

Phone Number*

Street Address

City

State

Zip Code


Student Information

First Name*

Last Name*

Birthdate*

Gender:

Grade in Fall 2017*)

School (required)


Emergency Information

Emergency Contact Name*

Relationship to Student*

Emergency Contact Phone*

Physician's Name

Physician's Phone

Insurance Carrier


Health History

Physical/Cognitive special needs or challenges?*

N/A if none.

Activities limited by physician?*

Any allergies, including food?*

Asthma? (required)

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


Health Care Providers

Specialty Doctor

Name:
Phone Number:

Health Doctor

Name:
Phone Number:

May we contact your students health care providers?

 Yes No

Add any comments about your students health care providers:


Medications

Does your student use an EpiPen?*

Does your student use an asthma inhaler?*

Currently taking medication?

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



Mental, Emotional, and Social Health

To help us better understand your camper and help your camper have a successful summer at camp, please be sure to tell us about ALL mental and emotional conditions, and ALL social and learning challenges your camper has experienced, especially any spec a1 needs, challenges and conditions with ADD/ADHD, or any restrictions as they may retate to camp. Success at camp is possible only with the accurate provision of information and close cooperation of the parent,. The information provided must be accurately completed for all campers. Any false or misleading information is grounds for immediate dismissal of the camper from the BAE Vet Camp program.

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

 Asperger's Syndrome Attention Deficit Disorder (Add or AD/HD) Autism Behavioral or Disruptive Disorder Bipolar or Mood Disorder Depression Disordered Eating Learning Disability Obsessive-Compulsive Disorder Other Mental, Emotional, or Social Health Condition Panic, Anxiety Disorder Sensory Processing Disorder Substance Abuse None of the above

Family Changes

Has your Student gone through any significant family changes (death, divorce, adoption, abuse, etc.)?

 Yes No


Background

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

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


Riding Level:

Riding Style:

Interested in Veterinary Medicine?

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

T-Shirt Size:

Do you own a horse?

At which stable do you ride?

How did you hear about us?

If you saw a flyer, where was it located?

Has your student been the subject of any disciplinary action resulting in school suspension?* If yes, please explain.

 No Yes

Does your student have a history of violence or fights?* If yes, please explain.

 No Yes

Has your student ever been arrested or charged with a criminal act?* If yes, please explain.

 No Yes


Authorized Individuals for Release

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.

Exclusive Workshops/Field Trip Permission

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.



Acknowledgements

Medical Policy

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

Allergy Policy

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

Tetanus & Rabies Waivers

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

Photo Release

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

Application Agreement

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

Student Testimonial Waiver

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

Waiver of Liability, Assumption of Risk & Indemnity Agreement

I have read, understand and agree to the Waiver of Liability, Assumption of Risk & Indemnity Agreement

Type your full name into the E-Signature box below. By doing so you acknowledge that is serves as a legal signature. You certify that the information entered in the registration form is true and correct as entered above.



E-Signature:

E-Signature Date: