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Horses of the Plains Science Adventure Camp
June 22-26, 2015
Registration Form
Registration Deadline June 1, 2015
A $75 check is required* to complete your registration for camp. The remaining balance ($75 for nonscholarship) will be due the first day of camp. *Registration fee not required at time of application if
you are applying for an income based scholarship.
INFORMATION RECORD
(Each child must have their own registration form)
CHILD’S NAME: ____________________________________ BIRTHDATE: ____/____/____ AGE: ______
SCHOOL: ________________________________________ GRADE COMPLETED THIS SPRING: ________
ADDRESS: _________________________________________ CITY: _______________________________
STATE: ______ ZIP: _________
EMAIL: ____________________________________________________
MOTHER/GUARDIAN’S NAME___________________________________HOME PHONE________________________
CELL PHONE____________________________
WORK PHONE ______________________________________
HOME ADDRESS_____________________________________________________CITY_________________________
STATE______________ZIP_______________
FATHER/ GUARDIAN’S NAME___________________________________HOME PHONE________________________
CELL PHONE____________________________
WORK PHONE ______________________________________
HOME ADDRESS_____________________________________________________CITY_________________________
STATE______________ZIP_______________
PERSON(S) TO WHOM THE CHILD(REN) MAY BE RELEASED BY THE CAREGIVERS (IF NO ONE, PLEASE WRITE
“NONE”)
NAME________________________________________________PHONE_____________________________________
RELATIONSHIP TO CHILD_______________________________CELL PHONE________________________________
NAME________________________________________________PHONE_____________________________________
RELATIONSHIP TO CHILD_______________________________CELL PHONE________________________________
T-Shirt Size
Child
____Small
____Medium
____Large
____X-Large
Adult
____Small
____Medium
____Large
____X-Large
PICTURE RELEASE: From time to time, pictures are taken of the children doing program activities, for the local
newspaper, television station or other promotional material for the supporting agencies and the camp itself. It is essential
to have parental permission before any pictures may be published. If you do not give permission, please still return this
form, and we will ensure no photos are taken of your child(ren). Please fill out and sign below.
� Yes, I give my permission for picture(s) of my child(ren) to be published in the local newspaper, television station or
High Plains Science Adventure Camp promotional material.
� No, I do not give my permission for picture(s) of my child(ren) to be published in the local newspaper, television station
or promotional material.
______________________________________
Parent/Guardian Signature
PARENT/GUARDIAN’S AUTHORIZATION
In Consideration of my above named child(ren) being allowed to participate in the Horses of the Plains Science
Adventure (HPSA) Camp and intending to be legally bound, I hereby waive, release, hold harmless, covenant notto-sue, and forever discharge any and all rights, actions, and claims of negligence that I or my heirs, executors,
or assigns may have against the HPSA Camp as well as their respective officers, directors, trustees, agents,
employees, representatives, successors, assigns, and affiliates for death, injury, loss, and any and all damages
that my child(ren) may sustain and/or suffer in connection with his/her/their participation in the HPSA Camp. I
also agree to indemnify the HPSA Camp for any defense, cost, or expense arising out of any claim of injury or
death arising from his/her/their participation in this program. I am both legally competent and am legally
responsible for the child(ren) listed below, who will be freely participating in this activity.
CHILD’S NAME___________________________________________________________________________
PARENT/LEGAL GUARDIAN’S SIGNATURE____________________________________________________
PERMISSION TO TRANSPORT
As part of the Horses of the Plains Science Adventure Camp, we will be transporting students in a Western Nebraska
Community College bus. As a part of this agreement, students will be required to fill out the WNCC registration form.
Please fill out the highlighted section below.
Horses of the Plains Science Adventure Camp
June 22-26, 2015
CAMPER MEDICAL INFORMATION / RELEASE FORM
CONSENT TO CONTACT PHYSICIAN IN EMERGENCY:
In the event I cannot be reached to make arrangements, I hereby give my consent to the Horses of the Plains
Science Adventure Camp Staff to contact Doctor(s) and, if necessary take my child(ren) to the following
doctor(s), clinics, or hospital. The Horses of the Plains Science Adventure Camp does NOT carry insurance on
camp participants. Any medial bills incurred are the responsibility of the parents.
_______________________________________s
Parent/Guardian Signature
Family Doctor: __________________________________
Address: ______________________________________
Phone #: _______________________________________
Dentist: ________________________________________
Address: _______________________________________
Phone #: _______________________________________
Other providers, clinics, and hospitals: _______________________________________________________________
Any HEALTH problems which the caregivers should know:__________________________________________________
PHYSICAL RESTRICTIONS:_________________________________________________________________________
LIST ANY BEHAVIOR OR OTHER SPECIAL CONSIDERATIONS: ___________________________________________
ALLERGIES (if any): ________________________________________________________________________________
MEDICATIONS (if any): _____________________________________________________________________________
HEALTH and/or ACCIDENT INSURANCE COVERAGE: ___________________________________________________
IF THE PARENT (OR GUARDIAN) CANNOT BE REACHED (AT LEAST ONE NAME MUST BE GIVEN.)
NAME ____________________________
NAME ______________________________
ADDRESS__________________________
ADDRESS ___________________________
CITY________________PHONE___________ CITY______________PHONE______________
RELATIONSHIP________________________ RELATIONSHIP________________________
**A $75 check is required for non-scholarship applicants to complete your registration for
camp. The remaining balance of registration ($75 for non-scholarship) will be due the first day
of camp**
Send Completed Registration Form and check to:
Alexandra Mayes
Horses of the Plains Science Adventure Camp
330243 C.R. H
Minatare, NE 69356
Registration Deadline June 1, 2015!
2015 Scholarship Application Form
Income based Scholarship
Scholarships are provided by local agencies
To qualify for a scholarship, students must handwrite 2 paragraphs (3-5 sentences/paragraph) telling
the scholarship committee why they would like to attend the Horses of the Plains Science Adventure
Camp. Scholarship form and student written paragraphs must be returned with registration packet by
June 1, 2015. You will be notified about your scholarship status prior to the start of camp. The
bottom section must be completed by the school principal.
Student Name: _____________________________________________________________
Address: _______________________________________ City: ________________
State: ________________ Zip: _____________
Grade completed this year: __________ School you attend: _________________________
Guardian’s E-mail address:______________________________________________________
(we can send you an e-mail to let you know that status of your scholarship)
Father/Guardian’s Name: _______________________________________________________
Address: ________________________________________ City: ________________
State: ________________ Zip: _____________ Phone: ______________________________
Mother/Guardian’s Name: _______________________________________________________
Address: _______________________________________ City: ________________
State: ________________ Zip: _____________ Phone: ______________________________
Section to be completed by School Principal (required)
Check One:
______ Student qualifies for reduced lunch
______ Student qualifies for free lunch
Principal’s Signature: ___________________________________________________________
Principal’s Name: _____________________________________________________________
School ____________________________
Phone: _______________________
Principal’s Email Address: ___________________________________________
*if you have questions related to scholarship qualification, please contact us at:
[email protected]
This form, the student paragraphs, and the competed registration packet must be sent via
email to the above address or mailed to the address listed below by June 1, 2015.
Alexandra Mayes
HPSA Camp
330243 CR H
Minatare, NE 69356
RELEASE
By signing my name at the bottom of this Release, I agree that, for and in consideration of the opportunity to ride a
horse provided by this state park, I agree to pay for such ride and further agree as follows:
1.
That I know and understand that this horse riding activity involves specific risks of property damage or
personal injury to me or to my minor children arising from approaching, handling, mounting, riding, and
dismounting the horse and from observing or participating in this activity; and I know and understand that a
horse, irrespective of its training and usual past behavior and characteristics, may act or react unpredictably at
times based upon instinct or fright which likewise is an inherent risk assumed by a horseback rider.
2.
That I hereby release and forever discharge the State of Nebraska, its agents, and employees from all present
and future claims arising from personal injury or property damage sustained by me or by my minor children
during the use of the horse, and I shall assume all risk related to horseback riding.
3.
That I waive my right to file and promise not to file any legal proceedings against the State of Nebraska, its
agents, or employees for any personal injury or property damage sustained by me or my minor children during
this activity; and I shall pay all costs and attorney’s fees from any legal proceeding which I may bring contrary
to this agreement and which is resolved in favor of State of Nebraska, its agents, or employees.
4.
That I sign this Release Agreement for and in consideration of the agreed price, and I hereby request the State
of Nebraska, its agents, or employees to choose for me and for my minor children a horse for the purpose of
riding same, knowing that the State of Nebraska, its agents, or employees are relying upon this Release
Agreement and the information that I have given to them concerning my experience and that of my minor
children with horses, including the potential hazards involved.
5.
That I have read the foregoing Release and sign it freely with full knowledge of its meaning and content.
Dated this _________day of _________________, 20_____
Name of Child _______________________________________
Signature of Person
Executing This Release
Check Level of
Riding Ability
Good
Fair
Poor
______________________
____
____ ____