InStride_Horsemanship & Farm Club

2021-2022 School Year
After-School Club Application

Please print and fill out this application completely. Membership expires on 5/2022.

Price: $45 per child, per week.
Child Information
Child's Name

First NameMiddle NameLast NameSuffix
Child's Address

Street Address

Street Address Line 2

CityState

Zip Code
Birthdate

MonthDayYear
Child's Age
Child's Gender
They identify as
Ethnicity
Please list Ethnicity
School
Grade in School

Child's Medical Concerns

If no allergies or medical problems, please write NONE in the boxes below.
Allergies
If no allergies, please write NONE
Medical Issues / Medical Needs
If no medical problems, please write NONE
Physician Name

First NameLast Name
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Insurance Company
Insurance Policy Number
Please explain any special needs/concerns child may have.

Parent / Guardian Information

Please list both parents unless one parent does NOT have legal rights to the child. Court Paperwork must be provided to prevent a parent from seeing their child.
Parent 1 Name

First NameLast NameSuffix
Parent 1 Relationship to Child
Parent 1 Other
Parent 1 Email
example@example.com
Parent 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent 1 Employer Name
Parent 1 Work Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent 2 Name

First NameLast NameSuffix
Parent 2 Relationship to Child
Parent 2 Other
Parent 2 Email
example@example.com
Parent 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent 2 Employer Name
Parent 2 Work Number
Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Information
Emergency Contact Name

First NameLast NameSuffix
Relationship to Child
Other
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Pickup Information

Please list a person, other than parent/guardian, who is authorized to pick up your child. They MUST have a government-issued photo ID when picking up. We will not release children to anyone that is not listed below. Please note that any changes to the pickup list must be done in writing – no phone calls.
Authorized Person 1 Name

First NameLast NameSuffix
Authorized Person 1 Relationship to Child
Authorized Person 1 Other
Authorized Person 1 Phone Number 1
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Person 1 Phone Number 2
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Person 2 Name

First NameLast NameSuffix
Authorized Person 2 Relationship to Child
Authorized Person 2 Other
Authorized Person 2 Phone Number 1
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Person 2 Phone Number 2
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Person 3 Name

First NameLast NameSuffix
Authorized Person 3 Relationship to Child
Authorized Person 3 Other
Authorized Person 3 Phone Number 1
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Person 3 Phone Number 2
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Person 4 Name

First NameLast NameSuffix
Authorized Person 4 Relationship to Child
Authorized Person 4 Other
Authorized Person 4 Phone Number 1
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Person 4 Phone Number 2
Please enter a valid phone number.Format: (000) 000-0000.
Additional Pickup

Have You Attached Legal Documents?
Rules, Waivers and Regulations
- I request my child be admitted to the InStride Equestrian Center’s After-School Club. It is expressly understood and agreed by the undersigned that the InStride Equestrian Center is not liable for the loss of property or injury. I also grant the InStride Equestrian Center permission to authorize and obtain medical care in case of illness and injury when neither parent/guardian is available to grant permission for emergency treatment. I understand that my child’s attendance may be suspended or cancel at any time, the sole decision resting in the judgment of the Program Director.
- If my contact information (home phone, cell, address, etc.) changes, I will let InStride Equestrian Center know immediately. This is a very important safety issue.
- InStride Equestrian Center hours of operation are afterschool - 6 pm.
- All late fees are due the day of the infraction. If late fees are not paid in a timely fashion, I understand this can result in my child’s attendance to the After-School Program will be suspended. The InStride Equestrian Center is obligated to contact Child Protection Services or the Police if a child is left at the Club one hour after closing. We will attempt to contact the parent/guardian and anyone on the pickup list to try and avoid this. Please keep all of your information up to date.
- I understand that if the InStride Equestrian Center staff contact me regarding my child being sick or hurt that I will pick up my child immediately or make arrangements for them to be picked up.
- I give permission for the individuals I have listed to pick up my child daily or as necessary from InStride. I also accept that my child will not be released to anyone who is not on the list. Furthermore, I agree that each authorized individual will be required to show a government-issued photo ID.

Rules, Waivers and Regulations
Media Permission Form

Use of Name, Photograph and Identity in Connection with Advertising and/or Promotion of the organization For valuable consideration I, the undersigned, hereby irrevocably consent to and authorize the unrestricted use by InStride Equestrian Center of my child’s name, photographs, works of art and identity in various InStride website, social media and collateral material, as well as miscellaneous print publications and other media outlets, and any personal information that I supply to the Companies, in connection with advertising and promotion of the Companies and/or their products in any media, form or material selected by the Companies, without any right of prior review or further approval, whether such advertising and promotion is to the public, to the trade, or both, and in the corporate releases, newsletters and other communications of the Companies; and I hereby waive, and release and discharge said Companies and all agents, employees and officers of the Companies, including their agencies, media producers and customers from, any claims, liabilities and demands, past, present or future, including any that I do not now know of or anticipate arising in the future, none of which would affect my execution of this release if known to me, and waive all rights with respect to such use of my name, photograph, identity, and personal information including but not limited to publicity, privacy, psychological injury and libel.
Permission Status
Medical Emergency Consent

I consent that in the event of a medical emergency that my child be given medical treatment at a local hospital, which may include transportation on an ambulance. I also give consent for the InStride Equestrian Center staff to act in my absence as guardian of my child in the event of a medical emergency.
Permission Status

Payment Information
Credit Card Authorization

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until canceled.
Name on Credit Card

First NameLast NameSuffix
Address

Street Address

Street Address Line 2

CityState

Zip Code
Credit Card Number
Security Code
Expiration Date
I, blanks , authorize InStride Equestrian Center to charge my credit card above for agreed-upon purchases. I understand that my information will be saved to file for future transactions on my account.

Rules, Waivers and Regulations
PLEASE NOTE ALL FEES ARE NON-REFUNDABLE. BY SIGNING BELOW, YOU ARE STATING THAT YOU UNDERSTAND THIS POLICY.

I hereby certify that I am the legal parent/guardian of the member listed on this application and approve my child’s application for admission into the After-School Club at the InStride Equestrian Center. I understand that it is my responsibility to notify the InStride Equestrian Center of any changes that may affect my child’s Club account.
Signature
Should be Empty:

2021-2022 School YearAfter-School Club Application

Child Information

Child's Medical Concerns

Parent / Guardian Information

Emergency Contact Information

Pickup Information

Have You Attached Legal Documents?

Rules, Waivers and Regulations

Rules, Waivers and Regulations

Payment Information

Credit Card Authorization

Rules, Waivers and Regulations

2021-2022 School Year
After-School Club Application