Madisonville Equestrian Center, 135 Vista St., Madisonville, LA 70447
(985) 778-6981
Lesson, Camp, Field Trip, and Birthday Party Enrollment
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General Information:
Name: ______________________________________ Sex: _________________________________
Birthdate________ Age: _______Parent/Guardian Name: ___________________________________
Home Phone: _________________ Work Phone: _______________Cell Phone: _________________
Address: ___________________________________________________________________________
City: __________________________State________________ Zip: ___________________________
School Currently Attending: ____________________________________Grade: ________________
Lesson Day(s)______________ Time_____________ Private_________ Group__________Monthly________
Fee Pd. Weeks Paid: _______________ Camp Date:
EMAIL:______________ Birthday Party Date
In Case Of Emergency Contact:
Name: __________________________Phone: ___________________Relation: _________________
Name: __________________________Phone: ___________________Relation: _________________
Name: __________________________Phone: ___________________Relation: _________________
Physician: ____________________________________Phone: _______________________________
Insurance: ________________________PolicyNo: ________________________________________
Acknowledgment of Risks:
I have enrolled my child in the Madisonville Equestrian Center program. I
understand that children enrolled in this program will participate in various activities, each of which involves a variety of
physical exertion and physical contact. I understand that injuries can and do occur and I am aware of such risks. I am
not aware of any medical illnesses or restriction which might prevent my child from participation in any of these activities,
except for the following; (If none, indicate)
My child has my permission to participate in all activities.
In the event of a medical emergency requiring more than basic first aid, I understand that all feasible attemps to contact me
will be made. I understand that in order to obtain the quickest medical treatment for my child, an ambulance may be
called to transport my child to the nearest emergency care facility. Rather than follow this procedure, I request that the
following alternative plan be adopted for my child; (if none. so indicate)
Date:
Parent/Guardian Signature: