Rider's age and horseback riding experience______________________________

_________________________________________________________________

Parent's Name______________________________________________________

Address___________________________________________________________

            City________________ State ___________  Zip Code ______________

Phone number (home)_________________________(work)__________________

In case of emergency contact___________________________________________

_________________________________________________________________

Physician and Hospital_______________________________________________

__________________________________________________________________

DATE of Camp attending _______________________________________

*All Day Camp is open only to those attending all day - there are NO half day spots during that camp!

Half - day camps $150.00 ; Whole - day camps $250.00 ;

Enclosed deposit
( ) $50 for half day camp 9-12  ( ) $100 for whole day camp 9-3

Please make checks payable to Southern Hills Riding Academy
Mail to: 7600 South Elwood Ave., Tulsa, Oklahoma, USA, 74132
______________________________________________

Warning: I, the parent or guardian of the minor listed above, do hereby request Southern Hills Riding Academy, Tulsa, Oklahoma, to accept my child or ward as enrolled for activities in said Southern Hills Riding Academy. I, as an adult and as the parent or guardian of said minor, know that by the very nature of the activities at Southern Hills Riding Academy - riding horses, care of the same, and related uses of the animals as well as running about and playing - there exists some element of risk or injury. I accept said risk and agree to hold harmless the owner or employees of Southern Hills Riding Academy in the event my child or ward is injured during his or her stay at Southern Hills Riding Academy. I have read this, agree with it, and have advised my child or ward to obey rules of the Academy. I personally carry hospital insurance on my child or ward and accept this responsibility. I, the undersigned do hereby authorize, and give permission to Southern Hills Riding Academy and its staff, individual or together, to act on behalf of the undersigned in requesting and authorizing the provisions of emergency medical services as deemed necessary in their discretion, to the child or ward. The undersigned guarantee payment of all services. This release\authorization shall be effective during the period that the child or ward is involved with Southern Hills Riding Academy and is not revocable during such period.

Signature(parent or guardian)_______________________ Date _____________