Black Creek Hill Farm
Sign Up Sheet
Child’s Name: _____________________________ Date of Birth: _________________
Parents’ Name: ___________________________________________________________
Best contact number: _________________ Mother□ Father□ Other□ ____________
Alternate number: ____________________ Mother□ Father□ Other□ ____________
TIME: 9:00AM-2:00PM Daily
____ April 10 - April 14 Spring Break Camp
__June 12 - June 16 Summer Camp
__June 19 - June 23 Summer Camp
__June 26 - June 31 Summer Camp
Specify individual dates if not attending the weekly camp.
Known medical conditions and required medications:
Primary Physician: _________________________
Telephone Number: ________________________
Make your check payable to: Black Creek Hill Farms
Total amount due per 1/2 day Week session: $250per child
Deposit in the amount of $75 is required with registration form, balance due on first day of camp.
Total amount due per 1/2 Daily session: $50.00 per child
Payment is due with registration form.
Mail completed Registration form and check to:
Black Creek Hill Farms 6019 NC Hwy 50 North
Benson, NC 27504
Equine Liability Bill & Photo Release
In order to be protected, professionals or the equine activity sponsors business must display a warning notice in clearly readable print. The sign must contain the following warning notice:
Under North Carolina law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in equine activities resulting exclusively from the inherent risks of equine activities. Chapter 99E of the North Carolina General Statutes.
The owners of Black Creek Hill Farms, all other sponsors and participants shall not be held responsible or liable for any accidents, injuries, damages or deaths occurring to any person, animal or property. I understand and agree to all the above statements.
I grant to BCHF, its representatives and employees the right to take photographs of me and my property in connection with the above-identified event. I authorize BCHF, its assigns and transferees to copyright, use and publish the same in print and/or electronically.I agree that BCHF may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
Signature: ______________________________________ Date: ___________ (Parent or Guardian must sign for rider under 18 years of age)