Lazy River Pony

Summer Camp Application Form

Name: ______________________________________ Date of Birth: ___/___/__

Address: _______________________________________________________________

City: ____________________ State: ________ Zip: _______________

Father’s Name: ___________________ Phone (H): ______________ (W): _________

Mother’s Name: ___________________ Phone (H): ______________ (W): _________

Contact in case of emergency: ___________________ Phone: ______________

Medical Concerns: _______________________________________________________

Doctor: _______________________________________ Phone: __________________

Hospital: _________________________________ Insurance Carrier: ____________

Allergies: _______________________________________________________________

Level of Experience: ________________________________

Date of Session Desired: ________________________________

Special Instructions: _____________________________________________________

Cost: __________________ Paid: _____________________________

(Check payable to Lee Thomas) 6524 Corrales Rd. Corrales NM 87048

505-897-0367

Signature of parent or guardian: __________________________ Date: ___________