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Youth Summer Camp - June 26-30, 2023
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" indicates required fields
1
Basic
2
Family Info
3
Details
4
Basic
5
Payment
Youth Summer Camp - June 26-30, 2023
Price:
Camp runs Monday through Friday from 10 a.m. to 3 p.m. for children ages 5-12. All campers must bring a lunch and refillable water bottle. Recommended farm attire is comfortable long pants and walking shoes. Be sure to apply sunscreen and bug spray, too. If you have smooth-soled boots with a heel for riding, please bring those, too. Helmets will be provided.
Parent/Guardian Name
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First
Last
Phone Number
*
Email
*
Name of Rider
*
First
Last
Rider's Birthday
*
Month
Day
Year
Age at Program Start
*
Rider's Home Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
These next questions are for you, the Parent/Guardian.
Have you participated in Diettrich Farm programming before?
*
Yes
No
Which programs have you participated in?
How many times have you ridden before?
Do you currently own or lease a horse?
*
Yes
No
Have you ever owned or leased a horse before?
Yes
No
Name of School Attended
Sex
*
Weight
*
Height
*
T-shirt Size
*
Youth-Small
Youth-Medium
Youth-Large
Youth-XL
Adult-Small
Adult-Medium
Adult-Large
Adult-XL
I am coming to Diettrich Farm to
*
Check all that apply
Have fun
Become a safe rider
Ride: Trail
Ride: English
Ride: Western
Ride: Show
Ride: Other
How did you head about Diettrich Farm?
*
Check all that apply
Returning Rider
Friend/Referral
Facebook/Instagram
Google/Internet
Flyer
Other
Are there any other goals the rider would like to work on?
Overnight Camp?
My child is interested in a possible overnight camp (extra charge)
In some weeks, overnight camp may be possible. Check this box if you’re interested. (Please note that overnight camp is not guaranteed. When overnight camp is possible, there will be an upcharge of $1,000. You will not be charged for this today.)
Emergency Contact Name
*
Someone other than yourself
First
Last
Emergency Contact Phone Number
*
Does the rider have any health problems we should be aware of? Please explain.
*
Also, include any allergies.
Billing Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Credit Card
*
American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number
Expiration Date
Month
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
Year
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
Security Code
Cardholder Name
Service Charge
*
Pay Now Online (service charge)
Total
Consent
*
I agree to the Diettrich Farms release of liability.
RELEASE OF LIABILITY FOR HORSE ACTIVITIES
NOTICE: A person who is engaged for compensation in the rental of equines or equine equipment, or tack or in the instruction of a person in the riding or driving of an equine or being a passenger upon an equine is not liable for the injury or death of a person involved in equine activities resulting from the inherent risks of equine activities, as defined in section 895.481(1Xe) of the Wisconsin Statutes.
By my signature below I acknowledge that I assume full responsibility for my safety and understand and appreciate the risks involved in riding a horse. I understand that by executing this agreement I am waiving any right I have to hold Lynn Diettrich Farm LLC, Lynn Diettrich Trust, Barbara Diettrich, it's Employees, Agents, Owners, Managers, etc, and Lynn Diettrich liable under any theory of liability for injuries or other damages I may suffer as a result of my taking riding lessons or the use of horses or equipment. I also acknowledge that the releases and waivers I am hereby executing shall be binding upon my heirs and representatives as well as myself. I further understand that the above entity makes no representations, nor express or implied warranties as to the quality and character of the horses and equipment furnished.
I agree to hold harmless and indemnify Lynn Diettrich Farm LLC, Lynn Diettrich Trust, Barbara Diettrich, its Employees, Agents, Owners, Managers and Lynn Diettrich and further release them from any liability or responsībility for accident, damage, injury, or illness to the undersigned or to any horse owned by the undersigned or to any family member or spectator accompanying the undersigned on the premises.
WARNING:
BEFORE SIGNING THIS FORM, I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND ALL OF THE INFORMATION CONTAINED THEREIN, I ACKNOWLEDGE THAT I DO NOT NEED ANY FURTHER EXPLANATION OF ITS CONTENTS AND WAIVE ANY FURTHER EXPLANATION. I HAVE VOLUNTARILY AGREED TO ITS TERMS AND PROVISIONS, UNDERSTAND AND AGREE THAT I HAVE OTHER FACILITIES TO CHOOSE FROM, AND AGREE THAT NO OTHER STATEMENT, REPRESENTATIONS OR INDUCEMENT, APART FROM WHAT IS STATED IN THIS AGREEMENT, HAVE BEEN MADE TO ME TO OBTAIN MY CONSENT AND MY SIGNATURE.
Photo Consent
I agree to the photo release at Diettrich Farm
By checking this box, I allow Diettrich Farm the use of any pictures taken for Facebook, website, social media, and advertisements, including brochures, flyers, etc of myself and my registered rider.
Release of liability signature
Phone
This field is for validation purposes and should be left unchanged.
Diettrich Farm - Salem, WI
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