Provide us your information *required field First Name*Last Name*Company / Business OrganizationPhone*Email* Subscribe to our newsletter. Type of Enquiry*General EnquiryMembership EnrolmentCamp EnrolmentSupport UsVolunteersRequest an Appointment / Triage Camp Enrolment Form Section A: Membership Enrolment Form Support Us1. DetailsRiders NameDate of Birth Date Format: MM slash DD slash YYYY AddressSuburbPost CodeContactPhMobileEmail Name of parent or guardian contactPhone No. In case of emergencyAny Medical Conditions2. Lesson TimesDayTime2. Days AttendingDays Attending Wednesday 17th April Thursday 18th April Tuesday 23rd April Wednesday 24th April Tuesday 9th July Wednesday 10th July Thursday 11th July Tuesday 16th July Wednesday 17th July Thursday 18th July Tuesday 8th October Wednesday 9th October Thursday 10th October * Camp dates subject to changeNumber of days* Price: $ 100.00 Quantity: * Price is subject to change. * This fee is non-refundable once booking is made.Total $ 0.00 Section B: Personal, Parental or Guardian medical consent formMedical ConditionsYesNoMedical Condition Type Allergies Asthma Autism Bleeding tendencies Cerebral Palsy Cranial Shunt Diabetes Downs Syndrome Epilepsy Fainting Turns Flaccidity Heart Problems High/Low Blood Pressure Impaired Balance Impaired Bladder/Bowel Impaired Circulation Impaired Hearing (Deaf) Impaired sensation Impaired Sight (Blind) Impaired Speech Infectious Disease Carrier Intellectual Disability Skin Problems Spina Bifida Splints/ Braces/ Corset History of Aggressive behavior Any other medical condition Name of Medical Practitioner Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last AddressTelephoneFaxBrief HistoryDiagnosisRelevant Medical InformationGeneral InformationNature of DisabilityAge of onset of DisabilityHeightWeightOther relevant informationSECTION C – Required if you have medical conditionSelect Type of Donation*Bale of Hay ($15)Bag of Lucerne Chaff ($30)2 Bags of Pony Cubes ($50)Set of shoes for a horse ($100)Quarterly worming of all horses ($500)Sponsor a Horse for a year ($1000)Credit Card* American ExpressDiscoverMasterCardVisa Credit Card Number Exp Date Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 CVV Code Cardholder Name Comments/Questions This iframe contains the logic required to handle Ajax powered Gravity Forms.