Wallington Park

Entry Form for the Camp Dated: *

First Name

Last Name

Email

Address *

Street Address

Address Line 2

City

Postcode

State

Country

Phone *

Male/Female & Age *

Bringing Own Horse? *

Yes
No

Horse's Name

Mother's Full Name

Home Number

Work Number

Mobile Number

Father's Full Name

Home Number

Work Number

Mobile Number

Name

Relationship to Rider

Home Number

Work Number

Mobile Number

Medicare Number

Name of Family Doctor

Contact Number

Please check if you have any of the following

Asthma
Diabetes
Fits of any type
Heart Condition
Dizzy Spells
Migranes
Blackouts
Uneven Pupils

Other

Do you require a vegetarian option?

Yes
No

Do you suffer from any allergies?

Yes
No

If yes, please list name and severity of your allergy and any medication required

Name of Drug

Type of Food

Describe Reaction

It is particularly important that people dealing with horses are immunised against tetanus. Tetanus is normally given at five years of age as Triple antigen or CDT and at fifteen years of age as ADT. Year of last tetanus immunisation

Is it necessary for your child to carry their own medication at all times?

I authorize the instructor in charge to administer first aid and call an ambulance if necessary for the medical attention of my child. I agree to bear any cost thereby incurred *

Yes
No

Covered

Yes
No

Membership Number

Expiry

Name of Company

Type of Cover

Contact Name

Contact Phone

Contact Email

Subject

Message

1. Please tick the appropriate box if your child suffers from the following:

Bed Wedding
Sleepwalking
Soiling
Seizures
Diabetes
Headaches
Vision Impairment
Hearing Loss
Dizzy Spells
Heart Condition
Blackouts
Hay fever
Asthma
Fears/Phobias
Other

If Yes, please give details:

2. Does your child have any chronic illness, medical condition, or physical restriction? YES / NO

3. Please tick the box which best describes your child’s ability to swim:

Excellent
Good
Poor
Non Swimmer

Further Comments:

4. Is this your child’s first trip away from home without you?

YES
NO

5. Please tick the appropriate box if you child has been diagnosed with any of the following:

Autism
Tourette ’s syndrome
ADHD
Intellectual Disability
Physical Disability
ODD
Mental Health Condition
Aspergers Syndrome
Other

If Yes, please provide a Behaviour Management Plan and further details:

6. Please tick the appropriate box if your child needs assistance with any of the following:

Bedtime
Toileting
Hygiene
Meal Times
Showering
Other

If Yes, please give details:

10. All prescribed medication is the be provided in a pharmacy issues Blister Pack, Webster Pack, or Dossette Box, that is clearly labeled. If your child is on medication, please list below:

Medication Name

Dosage - Before B/Fast

Dosage - B/Fast

Dosage - Other times

Dosage - Lunch

Dosage - Other times

Dosage - Dinner

Dosage - Other times

Dosage - Bedtime

Further Comments and Side Effects:

PARENT'S/GUARDIAN'S STATEMENT

PARENT'S/ GUARDIAN'S SIGNATURE

DATE

Horse Riding Week Camps

Quick Links

We are a professional riding school

Contact

03 5250 1788

Horse Riding Week Camps

We are a professional riding school

Subscribe to our mailing list

03 5250 1788