2019 Summer Camp at Midnight Farm

CAMPER INFORMATION

Bring sack lunch or dinner to camp. Snacks and water provided

Gender *
calendar

PARENT/GUARDIAN INFORMATION

Are you a CLO employee or Midnight Farm volunteer? *
 

Alternative Emergency Contact (other then parent/guardian listed above)

Please indicate the camp &/or activities the applicant is applying.

2019 Special Needs Summer Camp:
2019 All Abilities Performing Arts Camp:
Additional fees for camps:

GENERAL BACKGROUND

Mobility: *
Transfers: *
Assistive Devices *
 
Does camper have difficulties expressing thoughts or wants? *
Does camper use the following devices?

PERSONAL CARE

EATING ASSISTANCE *
DIET *
 
RESTROOM ASSISTANCE *
DRESSING ASSISTANCE

Health Information and Restrictions

SEIZURES *
Diabetes *
Allergies *
 
Has applicant ever required any psychiatric treatment/counseling or hospitalizations? *
Does applicant have a shunt? *
Does applicant menstruate? *
Do they need assistance with products:
Tetanus Shot: *

SOCIAL BACKGROUND

Can applicant read? *
Does applicant have any special behavior problems? *

Consent for Photography

For valuable consideration given and which is herby acknowledged, the undersigned herby grants to Midnight Farm permission to take, or have taken, still and moving photographs and films of the above named Participant, including television pictures, and consents to and authorizes Midnight Farm, its advertising agencies, news media, and any other persons interested in Midnight Farm and its work, to use and reproduce the photographs, films or pictures, and to circulate and publicize the same by all means, including, without limiting the generality of the foregoing, newspapers, television media, brochures, pamphlets, instructional materials, books, and clinical materials.
With respect to the foregoing matters, no inducements or promises have been made to secure signature to this release other than the intention of Midnight Farm to use, or cause to be used, such photographs, films, and pictures for the primary purpose of promoting Midnight Farm and its work.
I give consent: *

RELEASE OF LIABILITY

I understand and agree that Midnight Farm, its officers, members, employees and agents will not be responsible for any damages to person, animal or property at the Midnight Farm Riding Center or its grounds, nor will they be responsible for any property lost or destroyed.  The undersigned rider or parent/guardian hereby releases Midnight Farm, its officers, members, employees and agents from any and all liability, claims and damages, injuries, or losses to their person or property during, or in connection with, or arising out of any class, lesson demonstration, show, clinic, event or other function, whether or not such damages, injuries, or losses result directly or indirectly from the negligent act or omission of such released parties.
 
WARNING:  Under Kansas Law (K.S.A. 60-4001 through 60 – 4004), an equine professional is not liable for an injury to, or the death of, a participant in equine activities resulting from the inherent risks of equine activities.  Inherent risks of domestic animal activities include, but shall not be limited to:
1. The propensity of domestic animals to behave in ways (i.e., running, bucking, biting, kicking, shying, stumbling, rearing, falling or stepping on) that may result in an injury, harm or death to persons on or around them;
2. the unpredictability of a domestic animal’s reaction to such things as sounds, sudden movement and unfamiliar objects, persons or other animals;
3. certain hazards such as surface and subsurface conditions;
4. collisions with other domestic animals or objects; and 
5. the potential of a participant to act in a negligent manner that may contribute to injury to the participant or others, such as failing to maintain control over the domestic animal or not acting within such participant’s ability.
 
In exchange for the use of property owned by Midnight Farm and other valuable consideration, I agree that my use of the premises and any animals, facilities, or equipment owned by Midnight Farm is at my own risk.  I further agree to indemnify and hold harmless Midnight Farm, and its respective officers, members, employees, and agents, from any and all suits, actions, or claims of any type arising from my use of the premises or participation in an equine activity, or of such use or participation by my guest, whether or not such claims result directly or indirectly from the negligent act or omissions of the indemnified parties or otherwise.
 
Yes, I would like above named person to participate in the Midnight Farm Equestrian Program.  If the participant is my child, I have discussed this with the participant’s doctor.  I understand that NO LIABILITY can be accepted by any organization concerned with this instruction, including Midnight Farm, in the event of any accident that may occur.
 
No person can be accepted for participation in the Midnight Farm Equestrian Program until this form has been completed by the parent(s)/ guardian.  If the person is of legal age (18), he or she may complete the form if he or she is legally competent to do so.  All activities will be under strict supervision and, although every effort will be made to avoid any accident, NO LIABILITY can be accepted by any of the organizations concerned, including Midnight Farm.
 
I acknowledge that any involvement with horses is a high-risk activity.  I have read this notice and release of liability and fully understand and agree with its content. No refunds.
 
Agree *

Click the submit button below to make a secure online payment and complete your registration