2008
Registration Form
Name of Student:_________________________________ Age: __________________
Address:________________________________________________________________
City:______________________________ State:_______________ Zip:____________
Name of parent or guardian: ________________________________________________
Phone numbers of parent or guardian: Home_____________ Cell_________________
Email addresses of parent or guardian: ________________________________________
Please check program dates:
______ July 14 – 18 _____ July 28 – August 1
______ August 11- 15 ______ August 18 – 22
______ Other- Type of program:____________________________________________
Scheduled date and time:
______________________________ Fee: $_________
Cost is $200 per week-long program. Fifty dollar down payment required. Balance due on first day of program. Please make checks out to Dale Perkins.
Amount enclosed: $_____________
______ Check here to allow Mesa Farm to use the
participant’s likeness, through the use of, but not limited to photograph,
video, or film, for future promotional or public relations use. The undersigned releases any and all claims
for compensation for use of such images.
______ Check here if you think your child will be
participating in the 8:35 AM devotions prior to each mornings start of the
week-long morning riding program.
Participants should bring a sack lunch, appropriate clothing for outdoor summer weather conditions (shorts are not deemed appropriate for riding), and shoes with heels.
Parent/Guardian Signature: _________________________________ Date: __________
Return to:
Dale Perkins and Ann Tripp 508-886-6898