Touch Point Farm

Touch Point Farm Summer Day Camp Application – 2009

NAME OF CAMPER(S)_____________________________________________________ AGE(S)__________

NAMES OF PARENTS______________________________________________________________________

ADDRESS (# AND STREET)_____________________________________________________________________

(CITY, STATE, ZIP)______________________________________________________________________________

E-MAIL ________________________________________________CELL PHONE/BEEPER_______________

HOME PHONE __________________________________________WORK PHONE _____________________

CARPOOL INSTRUCTIONS/RESTRICTIONS____________________________________________________

I WOULD LIKE EXTENDED DAY: FROM 7AM = $5/ DAY £ TO 6 PM = $5/DAY £ (Circle: M T W Th F)

PREVIOUS RIDING EXPERIENCE:____________________________________________________________

£ WOULD LIKE TO BRING MY HORSE TO CAMP WITH ME:. CALL FOR INFORMATION ON AVAILABILITY & COST.

SWIMMING ABILITY: o NONE o VERY BEGINNER o BEGINNER/ BEGINNER+ o INTERMEDIATE o ADVANCED

TO RESERVE YOUR CAMP DATES, COMPLETE THIS APPLICATION INCLUDING THE RELEASE, AND RETURN IT WITH A DEPOSIT OF $150.00 FOR EACH WEEK DESIRED. THE REMAINDER $145.00(+) IS PAYABLE THE FIRST DAY OF THE SESSION. PLEASE MAKE CHECKS PAYABLE TO TOUCH POINT FARM. DEPOSITS ARE FULLY REFUNDABLE UNTIL MAY 15TH, AND THEREAFTER WHEN A REPLACEMENT CAMPER CAN FILL THE VACANCY. YOU MAY SIGN UP FOR MORE THAN ONE WEEK. MAIL YOUR DEPOSIT EARLY TO GET THE WEEK OF YOUR CHOICE. SESSIONS FILL UP QUICKLY, AND WE RECOMMEND APPLYING BEFORE JUNE 1^ST. THERE IS A $25. DISCOUNT FOR MULTIPLE WEEKS OR MULTIPLE SIBLINGS.

CHECK THE WEEK(S) DESIRED.

All levels of Riders $295 per week

__ Week of June 22 - 26 __ Week of June 29 - July 3 __ Week of July 13 - 17

__ Week of July 20 – 24 __ Week of August 3 – 7 __ Week of August 12 – 14

MAIL APPLICATION, RELEASE & DEPOSIT CHECK TO: TOUCH POINT FARM DAY CAMP 16251 DARK HORSE TRAIL CULPEPER, VA. 22701

IF YOU HAVE ANY QUESTIONS, PLEASE CALL (540) 547 - 2031 OR E-MAIL: camp@touchpointfarm.com

PLEASE INDICATE IF YOUR CHILD HAS ALLERGIES OR MEDICAL CONDITIONS THAT COULD AFFECT HIS/HER PARTICIPATION AT CAMP.

YOU MUST ALSO SIGN THE ATTACHED RELEASE

RELEASE AND HOLD HARMLESS AGREEMENT 

The Undersigned assumes the unavoidable risks inherent in all camp and horse-related activities, including but not limited to bodily injury and physical harm to horse, rider, camper, and spectator.

In consideration, therefore, for the privilege of riding, horse boarding, receiving riding instruction, and/or working around/with horses at Touch Point Farm (16251 Dark Horse Trail, Culpeper, Virginia), or other equestrian facility assigned, and including swimming, diving, sports (to include, but not be limited to, bicycling, scootering, skating, skateboarding), and/or other camp activities, the Undersigned does hereby agree to hold harmless and indemnify Touch Point Farm, LLC, Peter R.and Janet B. Schwenke, farm owners, Meredith Jones, instructor, other instructors invited to participate in camp lessons, camp counselors, life guards, and/or their assigns, and further release them from any liability or responsibility for accident, damage, injury, or illness to the Undersigned and his/her child/children, or to any horse owned and/or boarded by the Undersigned or to any other family member or spectator accompanying the Undersigned on the premises.

I, the Undersigned person, intending to be legally bound, hereby waive for myself, agents, guardians, heirs, executors, administrators, legal representatives, assigns, and any other persons, any & all rights & claims for damages, demands & any other actions whatsoever which I may have against any of the above named persons or their property, arising out of my equestrian/boarding activities, and/or camp/swimming/sports activities. I specifically agree not to sue any persons or entities indicated above.

By my signature, I acknowledge that I understand the above, & that handling and/or riding horses is considered a hazardous activity & that there are inherent risks, including (i) the propensity of an equine to behave in dangerous ways which may result in injury or death to the participant; (ii) the inability to predict an equine’s reaction to sound, movements, objects, persons, or animals; and (iii) hazards of surface or subsurface conditions. I assume full liability for any personal injury or property damage to my person, child/children, persons accompanying me, personal property and horse(s). (See Code of VA. Sec. 3.1-796.1.30 et seq.)

<>Additionally, I specifically authorize Peter R. Schwenke, Janet B. Schwenke, Meredith Jones, and/or their assigns, to seek professional medical assistance, at my expense, for __________________, should they feel it is in his/her/their/its best interests.

<>SAFETY HELMETS REQUIRED WHEN MOUNTED.

<div align="Center"><div align="Left">PRINT NAME OF SIGNER______________________________________________________

SIGNATURE OF PARENT FOR MINOR CHILD______________________________________</div></div>

DATE __________________________ PHONE #____________________________________

NAME OF MINOR CHILD/REN____________________________________________________

NAME OF EMERGENCY CONTACT ____________________________PHONE #___________

NAME OF MEDICAL INSURANCE & POLICY #_______________________________________

PLEASE ADVISE US OF ANY ADDITIONAL MEDICAL OR OTHER INSTRUCTIONS.