Madisonville Equestrian Center, 135 Vista St., Madisonville, LA 70447
(985) 778-6981
Lesson ,Camp,Field Trip and Birthday Party Enrollment
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_________  
Fee Pd.________  Weeks Paid:  _______________  Camp Date: _________Field Trip___________________
EMAIL:______________                                 Birthday Party
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)  

Parent/Guardian Signature/Date