Thank you! Your information has been submitted successfully. Please complete the Medical Statement for participation below and mail in the signed form, with your payment. MEDICAL STATEMENT FOR PARTICIPATION IN HORSEMANSHIP ACTIVITIES I To be filled out completely and signed by parent/guardian of horse camp participant. I I hereby certify that (he, she) is not under the influence of alcohol or drugs, or under treatment for any physical infirmity or Chronic ailment, or injury of any nature, and that (he, she) has normal vision and has never been treated for any of the following 1) Cardiac or Pulmonary condition or disease 2) High Blo6d pressure 3) Fainting spells or convulsions 4) Diabetes 5) Nervous disorders 6) Hard of hearing 7) Kidney or related diseases Has this camper had counseling in the past two years for behavior, family conflicts, self-esteem problems or needs? Yes__ No__ Does your child have ADD or ADHD? Yes__ No__ Is there any reason that your child may not be able to work in a group with the rest of the campers on a regular basis? Yes__ No__ If yes to any of these questions, please give more detail on a separate sheet. This helps us in assigning appropriate horses and activities for the campers. Allergies: _ Date of Participant's last Tetanus shot: (required) Signature of Parent/Guardian:____________________________________________ Date: ____________________________ RELEASE OF INTEREST I (parent name) _____________________________________________________am aware that Horsemanship activities may be HAZARDOUS ACTIVITIES, and I am VOLUNTARILY participating in these activities with knowledge of the DANGER involved and HEREBY ACCEPT ANY AND ALL RISKS OF INJURY OR DEATH (parent initial)___________ . In Addition, I HEREBY INDEMNIFY, RELEASE AND DISCHARGE Stables, Almaden Equestrian Center/Almaden Summer Horse Camp, and the trustees, Officers, Directors, Employees, and Agents thereof, and each of them, from all actions, claims, or demands I, my heirs, distributes, Guardians, Legal representatives or assigns now have or may hereafter have for injury or damage resulting from participation in horsemanship activities. Signature Parent/Guardian_______________________________________________ Date______________________________ (print) __________________________________________________________________________________________________ Signature Parent/Guardian_______________________________________________ Date______________________________ (Print)