Name of camper:___________________________ Date of birth:_____/_____/____

Address:_____________________________________________________________

City:_________________________ State:_________________ Zip: ____________

Father's name:____________________ Phone: (h)_____________ (w) ______________

Mother's name:___________________ Phone: (h) _____________ (w) ______________

Guardian signature________________________________________________________

Contact in case of emergency:_____________ Phone: (h) __________(w) ___________

Medical conerns:__________________________________________________________

Our strong emphasis on safety requires all students to wear boots and AST- approved
Helmets, and long pants.

Camp dates desired:

Level of riding experience (please circle)

Beginner Intermediate Advanced Showing

Number of years riding:______________________________

FEE: $240.00 FOR THE 4 DAYS
DEPOSIT, $100.00 MAKE CHECK PAYABLE TO D-TALK RANCH