Name of Student ____________________________________OHIP Number_______________

Name of Guardian ___________________________________Birth Date__________________

Address________________________________________________________________________

Telephone Numbers:

Home:____________________________________________

Office Mother :_______________________Office Father:______________________________

Mother Cell: ___________________________Father Cell: _____________________________

Family Physician : _______________________Phone : ____________________________

Allergies : _______________________________________________________________________

Previous Riding Experience:

_______________________________________________________________________________

_______________________________________________________________________________

Circle the week you are Applying for :

Camp Weeks
July 4 - 8
July 11 - 15
July 18 - 22
July 25 - 29
Aug 8 -12
Aug 15 - 19
Aug 22 - 26

Total payment for 5 day Camp 250.00 plus HST
Please make cheques payable to Trilliumview Stables
No charge for helmet rental but please come and reserve yours in advance.