Summer Camp Application

Parent/Guardian Name *

First

Last

Email *

Contact Number *

Address *

Camper's Name *

First

Last

Address of Camper (if different)

Age *

Height *

Weight *

Riding Level *

Parent/guardian authorizes the child to participate in field trips:

Yes
No

Payment

$100 non-refundable deposit ONLY
Full Camp payment $500

Registration Fee: $100.00 non-refundable check to be included with the camp application. Balance of camp fee due upon arrival of child. Mail check to Picturesque Farm 7769 Piccadilly Dr. Warrenton, VA 20186 with application. Make checks payable to Picturesque Farm.

2023 Summer Camp Sessions

Emergency Contact *

First

Last

Emergency Contact Number *

Relation to Child *

Child's Physician and Physician's Number

Any known allergies or intolerance to food, medication, etc

Does the child require any medicine on a regular basis?

Yes
No

If Yes, kind and frequency

Any other information deemed important

Insurance Company

Insurance Company Phone Number

Insured’s Name

Relationship to Child

Policy Number

Group Number

Medical Release Parent/Guardian Signature *

Picturesque Farm LLC agrees to notify the parent/guardian whenever the child becomes ill or needs medical attention. The parent/guardian authorizes Kristy Willwerth/Picturesque Farm LLC to obtain immediate medical attention if an emergency occurs when the parent/guardian can not be located immediately.

Riding Release Parent/Guardian Signature *

This release is given by the undersigned Rider/Horse Owner or Rider’s/Horse Owner’s Legal Guardian in consideration of the agreement by Kristy Willwerth t/a Picturesque Farm LLC to provide Rider/Horse Owner horseback riding facilities, horseback riding instruction, Horse Owner boarding facilities, horse shows or any other equine activity in which Rider/Horse Owner is a participant and shall be binding upon Rider’s/Horse Owner’s spouse, heirs, successors, executors, administrators, and legal representatives. Rider/Horse Owner understands that engaging in an equine activity means any person, whether mounted or unmounted, who rides, handles or trains an equine and any person who does not ride, handle or train but participates otherwise in an equine activity. Rider/Horse Owner understands the propensity of equines to behave in ways that may result in injury, harm or death to persons on or around them; the unpredictability of an equine’s reactions to such things as sounds, sudden movement, and unfamiliar objects, persons or other animals; certain hazards such as surface and subsurface conditions; collisions with other animals and the potential of the participant acting in a negligent manner that may contribute to injury to the participant or others, such as failing to maintain control over the equine or not acting within the participants ability. Rider/Horse Owner releases, discharges, and agrees to indemnify and hold harmless Kristy Willwerth t/a Picturesque Farm LLC, her employees, agents, representatives and owners from all actions, causes of action, claims, liabilities, judgments, costs expenses and other obligations whether or not occasioned by negligence without limitation, which arise out of Rider’s/Horse Owner’s horseback riding, horseback riding instructions, boarding of horses or other activities on or off premises owned/operated by Kristy Willwerth t/a Picturesque Farm LLC or which arise out of first aid or emergency medical treatment furnished Rider/Horse Owner by Kristy Willwerth t/a Picturesque Farm LLC, her employees and/or legal representatives. This release shall be construed so as to permit its enforcement to the fullest extent permissible under the laws of the Commonwealth of Virginia.