Summer Camp Application

 

  • Add a row
  • Add a row
  • NamePurposeQuantityTime 
    Add a row
  • NameRelationPhone 1Phone 2 
    Add a row
  • If your first choice is filled and you would like toe be considered for alternate sessions please indicate below
    High Hopes Therapeutic Riding, Inc. 1) to use my child’s photograph or image in its print, online and video publications; 2) release High Hopes Therapeutic Riding, Inc., its employees and any outside third parties from all liabilities or claims that I might assert in connection with the above-described activities and 3) waive any right to inspect, approve or receive compensation for any materials or communications, including photographs, videotapes, DVDs, website images or written materials, incorporating photos/images of me(my child).
  • (Name) would like to participate in the High Hopes Therapeutic Riding Inc. program. I acknowledge the risks and potential for risks of horseback riding and related equine activities, including grievous bodily harm. However, I feel that the possible benefits to myself/my child/my ward are greater than the risk assumed. I hereby, intending to be legally bound for myself, my heirs and assigns, executors, and administrators, waive and release forever all claims for damages against High Hopes Therapeutic Riding, Inc., its Board of Directors, Instructors, Therapists, Aides, Volunteers, and/or Employees for any and all injuries and/or losses I/my child/my ward may sustain while participating in the Program from whatever cause including but not limited to the negligence of these released parties. The undersigned acknowledges that he/she has read this Registration and Release Form in its entirety; that he/she understands the terms of this release and has signed this release voluntarily and with full knowledge of the effects thereof.
  • Authorization for Emergency Medical Treatment for Camp

    (to be invoked in the event that your Emergency Contact cannot be reached.)
  • If you choose non-consent for emergency medical treatment/aid in the event of illness or injury while on the property of the agency, please request a Non-Consent Form, which requires notarization.
  • Potassium Iodide (KI) Fact Sheet and Permission

    The State of Connecticut is making Potassium Iodide tablets (KI) available to child care facilities and youth camps within the 10-mile emergency planning zone around Millstone Power Station in Waterford, CT. KI is a form of iodine. It helps to protect the thyroid gland when there is a chance that you might be exposed to a harmful amount of radioactive iodine. In the rare event of a nuclear emergency, your child care provider will be directed when to administer KI through the Emergency Alert System (EAS). Children in child care and youth camps are of the age most likely to suffer the effects of radioactive iodine. Your childcare program or youth camp must obtain your written consent in order to administer KI pills to your child/children. Please remember that the administration of KI to your child under these emergency conditions is voluntary. Contraindications: • Your child should not take Potassium Iodide if he/she is allergic to iodine. • Your child should not take Potassium Iodide if he/she has chronic hives. • Although a single tablet of KI should be tolerated by most people, some (particularly adults), with a number of rare diseases and conditions should discuss this issue with their physicians. These conditions include: o Hypocomplementemic vasculitis, possibly as a component of lupus or chronic hives, o Autoimmune thyroid disease, such as Graves disease. • Potential side Effects: Please consult with your pediatrician if your child experiences any of these side effects: o Minor upset stomach o Rash
  • Next steps

    Thank you for completing our Summer Camp 2014 Registration! You will now be redirected back to the summer camp page. Please download the physician's form and the payment form. Have your physician complete and return the physician's form. Please send the payment form to High Hopes together with your check.