WildeWood Farm Camp Registration

Camper’s Name __________________________________________

Parent’s Name _______________________________________

Address_____________________________________________

            Phone Number __________________________

Work Number___________________________

E-mail _________________________________

Emergency Number______________ Relationship_____________

Age ____ Grade ______

Allergies ______________________________________________

Medications and dosage___________________________________

Physician ____________________Phone#____________________

Enclosed deposit of:  $150.00

Week(s) preferred ________________

Please make checks payable to WildeWood Farm, Inc. Checks may be mailed to WildeWood Farm, Inc. 4855 Heardsville Rd. Cumming, and GA 30040

  I, the parent or guardian of the minor listed above, do hereby request WildeWood Farm, Inc. Cumming, GA, to accept my child or ward as enrolled for activities in said WildeWood Farm, Inc. I, as an adult and as the parent or guardian of said minor, know that by the very nature of the activities at WildeWood Farm, Inc. – riding horses, care of same, and related uses of the animals as well as running and playing - there exits some element of risk or injury. I accept the said risks and agree to hold harmless the Owners or Employees of WildeWood Farm, Inc. in the event my child or ward is injured during his or her stay at WildeWood Farm. I have read this, agree with it, and have advised my child or ward to obey rules of the camp. I personally carry hospital insurance on my child or ward and accept this responsibility.

I, the undersigning do hereby authorize, and give permission to WildeWood Farm, Inc. and its staff, individual or together, to act on the behalf of the undersigning I requesting and authorizing the provision of emergency medical services as deemed necessary in their discretion, to the child or ward. The undersigning guarantees payment of all customary fees and charges in connection with the rendering of such medical services. This release/authorization shall be effective during the period that the child or ward is involved with WildeWood Farm, Inc. and is not revocable during such period.

Warning: Under Georgia law, an equine activity sponsor or 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 pursuant to Chapter 12 of Title 4 of the official code of Georgia Annotated.

Parent or Guardian: __________________________________  Date:__________