FIRE STORM 
EQUESTRIAN CENTER
 1-661-268-1715              1-661-268-8440 Fax
DAY CAMP
STARTING IN JULY - for approximate ages 9-13, boys and girls - Multiple programs available, look below or call for more details 661-993-9652 Lia - If you don't find a program that fits your needs please feel free to call and we will work to make a program that fit your child's need.
 

CLICK HERE TO SEE DAY CAMP FLYER
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TERMS, CONDITIONS, MEDICAL RELEASE  AND   APPLICATION

TERMS  AND  CONDITIONS.
    Horse sports, farm animals, farm equipment, lessons and equipment could be dangerous. Prior to start of day camp all participants parents will be required to sign the FSEC’s Assumption of Risk, Release Agreement. FSEC reserves the right to refuse service or terminate a camp participant at any time prior or during camp.
    If there is a situation that prevents day camp from continuing or if a camp participant is dismissed by FSEC a prorated refund will be given. All refunds are to be prorated minus the initial non refundable $80.00 for supplies per camp participant.
    FSEC has the right to substitute or omit without notice any of the speciality activities with the exception of horse back riding lessons.

Day camp dates available are July 7th, 2009 through August 21st, 2009.
Day camp is for 3 hours from 11 am to 2 pm
Lunch and snacks are provided daily
Horse back riding lessons from 11:00 am to 12:30 pm
Lunch from 12:30 pm to 1:00 pm
Specialized activities from 1:00 pm to 2:00 pm

With prior notice there is an optional 1 hour early drop off at 10:00 am for an additional $12.00 per day and one hour late pick up after camp for an additional $12.00 per day for pick up at  3:00 pm.

PRICING  AND  OPTION  OF  DATES.
#1) 2 days per week for four week = 8 lessons @ $380.00 (non refundable $80.00 for supplies included in price)
#2) 4 days per week for two weeks = 8 lessons @ $380.00 (non refundable $80.00 for supplies included in price)
#3) 4 days per week for four weeks = 16 lessons @ $660.00 (non refundable $80.00 for supplies included in price)

Please mark your choice of option#________,
__________________________________________________________________________________________
OFFICE USE ONLY
    Confirmation of dates     
    Copy of medical card
    Deposit check of $80.00 (pd ck #                _),  Balance of Camp $____________ (pd ck#                   )
    Signatures on terms and condition and releases
___________________________________________________________________________________________

Private English or Western horse back riding lessons and mini cart lessons are available for $35.00 per hour.

APPLICATION.

Mothers Name____________________________________Emergency #_________________________________

Fathers Name_____________________________________Emergency #________________________________

PARTICIPANTS  NAME_________________________________________AGE_________GENDER_________

Address______________________________________________________________________________________

____________________________________________________________________________________________

Home #_________________________Fax #______________________e-mail____________________________

Does your child have any health, medical or physical restrictions?_______________________________________
_____________________________________________________________________________________________
(if so will need a release from medical doctor to participate)
Page 1 of 2


Does your child take any prescription medications?___________________________________________________
____________________________________________________________________________________________
(if so will need a release from medical doctor to participate)

Does your child have any food restrictions (soda, nuts, jelly , or?)_______________________________________
____________________________________________________________________________________________
(Please list food restrictions in detail)

Does your child have any allergies?_______________________________________________________________
_____________________________________________________________________________________________

Does your child have special emotional needs?______________________________________________________
___________________________________________________________________________________________

What is your medical insurance carrier for your child__________________________________________________

Name of child’s physician__________________________________________Phone #______________________

Information needed to provide medical provider SS#’s_________________________, ______________________
                                                                                                                               (Parents)
Employer__________________________________________, ________________________________________

PARENTS  AUTHORIZE  FSEC / Lia Coulombe / AND HOSPITAL TO  MAKE  MEDICAL  DECISION  FOR PARTICIPATING   CHILD
    If your child seams to be seriously injured while at FSEC the fire department will be called and then emergency # ‘s provided by parents will be called. Once examined by fire department’s  EMT,  and if they determine that your child should be taken to the hospital FSEC will send someone with ambulance until parents can arrive. If EMT feels your child is medically fit FSEC will wait for parents decision to leave child for remainder of camp or pick up child early.
By signing below _____________________________________, _______________________________________
                                                                                              (parents)
parents of _______________________________________________________give FSEC / Lia Coulombe sole authorization  to call medical services prior to contacting parents and if parents can not be reached parents give FSEC / Lia Coulombe authorization to make sole decision if child needs hospitalization. Parents have provided a copy medical insurance card that is to be used  for medical services provided for child. (ATTACH COPY OF CARD) Henry Mayo Hospital is the closest hospital to FSEC and child will most likely be taken to HMH in Santa Clarita unless otherwise stipulated here(______________________________________________________) by parent. If parents can not be reached, parent gives providing hospital authorization to provide medical procedure necessary to stabilize participating child condition until parents can be reached.

By signing below parents have read, understood and agree with terms and conditions, pricing and options, medical release, conduct for participant, and attached assumption of risk, and release agreement.

Mothers signature____________________________________________date__________________________

Fathers signature_____________________________________________date_________________________

CONDUCT  OF  PARTICIPANT
I pledge not use profanity, treat other participants with fairness and kindness, pay attention and follow instructors instruction to insure my safety, treat animals with kindness, wear appropriate clothing to camp, work on any projects sent to finish at home, help my parents at home, be kind to my brothers and sisters, help other participants, and most of all have fun at camp. I ______________________________________________pledge to do my best follow the above list of conduct.

______________________________________________
(Participants Signature)

Page 2 of 2                                 TERMS, CONDITIONS, MEDICAL RELEASE  AND   APPLICATION

Click here for printable copy
of Assumption of Risk, Release
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 FIRE STORM EQUESTRIAN CENTER
   ASSUMPTION OF RISK, RELEASE AGREEMENT
    I, the undersigned, on behalf of myself and my personal representative, heirs, guardians, guest, next of kin, spouse, and assigns, and on behalf of my minor child (ren) named below, DO HEREBY AGREE THAT:
    (a) In consideration of the use of the premises of Fire Storm Equestrian Center, the undersigned recognized and agrees that participation in horse sports and horse related activities is DANGEROUS AND HAZARDOUS, AND MAY EVEN LEAD TO INJURY, PERMANENT INJURY, OR DEATH.
              (b) I RELEASE AND FOREVER DISCHARGE FIRE STORM EQUESTRIAN CENTER, and its officers, directors, partners, investors, shareholders, agents, owners, employees, sub contractor, all land owners, renters, lessees, volunteers, trainers, event organizers, adjoining land owners, owners of any equipment/vehicles/trucks on property, judges, event organizers, vendors, food suppliers, food preparers, food servers, trainers, coaches, Coulombe/Sarvis/Gros family members, West Coast Water Tenders, inc., High Torque Marine, inc., any and all affiliate Trusts and all instructors and other persons acting on their behalf or in concert with them ( hereinafter the ~RELEASED PARTIES~) FROM ANY AND ALL CLAIMS, LIABILITIES, AND LOSSES BASED ON NEGLIGENCE PASSIVE OR ACTIVE, STRICT LIABILITY, FAILURE TO WARN OR OTHERWISE, AND AGREE NOT TO SUE, AGREES TO HOLD HARMLESS, REGARDLESS OF NEGLIGENT ACTS OF OR OMISSIONS, OR BRING TO MEDIATION the RELEASED PARTIES for injury, permanent injury, death, losses of any kind, damages to me (or my child-ren) my horse(s), or any other person, animal or property, directly or indirectly arising out of or resulting from the riding, handling, participating, watching, helping, training, instructing, carting, transportation or stabling of any horse (whether owned, rented, leased, borrowed, RELEASED PARTIES, or otherwise) on the premises of the RELEASED PARTIES, or in any adjacent areas where horses are stabled, ridden, boarded or handled. I promise to indemnify and hold RELEASED PARTIES harmless from any loss, injury, damage, claim, judgment or expense that RELEASED PARTIES may arising out of my (and my child-ren) activities or presence on such or in such areas.
             (c) PARTICIPATING IN, OBSERVING, OR BEING IN THE PRESENCE OF ACTIVITIES INVOLVING HORSES, ponies, animals of any kind, including riding, vaulting, handling, carting, training, instructing, loading, transporting, boarding, stabling or care (whether or not under the supervision of parents, instructors, RELEASED PARTIES, coaches or trainers), POSES DANGER AND RISK OF INJURY OR DEATH to people, animals, property and livestock. I acknowledge that: (1) worn defective equipment, and other horses, spectators and riders are hazardous to me (and my child-ren), my horse(s), and property; (2) I have and will continue to inspect the horse(s), riders, saddles, bridles, barriers, gates or lack thereof, lighting or lack thereof, ranch vehicles and weather condition; (3) the facilities, vehicles, trucks, horse(s) and equipment of RELEASED PARTIES are NOT believed to be free of defects or deterioration; (4) the horses, riders, handlers, RELEASED PARTIES and spectators may not be trained, knowledgeable or experienced; (5) instructors, coaches and trainers may NOT assess correctly the skills, experience of ability of horse and rider, or the difficulty or danger of any jump course, riding exercises or activities; (6) the facilities have natural and unnatural hazards which include but are not limited to ditches, canyons, glass, wire, metal, dirt roads, cliffs, Highway, asphalt, jumps, structures and other obstacles, hills, rock's, water, ponds, gopher holes, uneven ground or footing, snakes, debris, low hanging trees, falling branches, farm equipment, water trucks, trailers, wood fencing and wild and domesticated animals of all kinds; (7) horses present in the area may have been known to bite, buck, rear, kick, bolt, become uncontrollable or misbehave without warning; and (8) the existence of dogs, birds, insects wild and domestic animals of all kinds, trucks, tractors, motorcycles, off road vehicles, farm equipment, cars, helicopters, planes, sprinklers, sirens, loud speakers, announcers, music, phones ringing, other vehicles, and noises in and around the area may pose increases hazards. (9) agree that as a condition of and in consideration of acceptance of entry, they authorize the RELEASED PARTIES to market, transfer, assign, or otherwise make use of any photographs, likenesses, films, broadcasts, cable casts, audio tapes, or video tapes taken of the horse(s) and the participant(s) while on the grounds, incident to, or in transit between the stabling facility and the event site, in any way they see fit or promotion, coverage, or benefit of the event, or service, and hereby expressly and irrevocable waive and release any rights in connection with sues use, including any claim to invasion of privacy, right of [publicity, or to misappropriation, I VOLUNTARILY ELECT TO ASSUME ALL RISKS, ASSUMPTION OF RISK AND AGREEMENT TO HOLD HARMLESS, connected with the entry of me (and my child -ren) and/or my hors(s) and/or my property onto the premises of the RELEASED PARTIES and adjacent areas, and with participating activities involving horses. I accept all responsibility for the safety of everyone in my party.
    (d) If any portion of this agreement is held invalid, the balance shall continue in full force and effect . I have not signed this agreement in reliance of any representation or inducement of the RELEASED PARTIES.
    e) NO riders under the age of 18 shall handle or ride the stallions, no riding bareback, no riding double, no running of participants and/or horses unless in designated area, dogs allowed if on leash at all times on RELEASED PARTIES property. Coach/Instructor shall be present at all times while their rider is on RELEASED PARTIES property. I represent that my horse(s) and I (and my child-ren) have the requisite training, coaching, and ability to safely complete in this competition. I agree (and my child-ren) to wear protective headgear when mounted or riding. When jumping, I agree (and my child-ren) to wear protective head gear and passing or surpassing the ASTM/SEI standards with harness attached that meet standards currently imposed by the U.S. Equestrian Rules for Event. I understand that the USEA mandates that all riders participating in cross-country / jumping activity measures needed for handling horses. Arm bands can be purchased from the USEA web site or by calling them.
*Horse Trainer = adult person assuming all legal liability for care of riders horse while it is on RELEASED PARTIES property. *Rider Coach/instructor = person who gives verbal instructions to the rider while he/she in on RELEASED PARTIES property.                                         
     I HAVE READ THIS DOCUMENT AND I UNDERSTAND IT INCLUDES A RELEASE OF CLAIM FOR INJURY, PERMANENT INJURY OR DEATH TO ME (OR MY CHILD-REN) AND FOR LOSS, THEFT, OR DEATH OF, OR INJURY OR DAMAGE TO MY HORSE(S) OR OTHER PROPERTY. THE UNDERSIGNED RECOGNIZES AND AGREES THAT BY EXECUTING THIS ASSUMPTION OF RISK, RELEASE OD LIABILITY AND INDEMNIFICATION AGREEMENT, HE OR SHE IS WAIVING AND RELEASING VALUABLE LEGAL RIGHTS. ALL SIGNATURES BELOW ARE MANDATORY WHEN ENTERING RELEASED PARTIES PROPERTY. OWNERS OF HORSES, RIDERS, TRAINERS, COACHES, INSTRUCTORS, SPECTATORS, PARENTS ARE TO CARRY THEIR OWN INSURANCES TO COVER ALL OF THE ABOVE MENTIONED DANGER AND LOSSES.

1) Rider Signature __________________________________Print Name_________________________________
                              (rider must be 18 or older to sign this release without a parents consent)

5) Parent./Guardian _______________________________Print Name __________________________________

DATE ______________________ ALL SIGNATURES MUST BE PRESENT OR ENTRY WILL NOT BE ACCEPTED.
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