Equine Vet Camp Registration

BAEVC Policies Document Agreement

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 BAEVC program.


Choose Your Package:

 Residential: $2,800 Commuter: $1,800


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*


Health Care Providers

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 #:


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.


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 BAEVC better understand your student and help your student have a successful experience at camp, please be sure to tell us about ALL mental and emotional conditions, and ALL social and learning challenges your student has experienced, including but not limited to any special needs, challenges and conditions such as ADD/ADHD, or any issues that may impact the student’s stay at BAEVC. In addition to the forgoing, has your student ever been diagnosed with any of the following mental, emotional, and/or social health disorders?

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

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

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

 Yes No

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


Background

Riding Level:

Riding Style:

Please share students past experience 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?


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
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.

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: