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 Tuesday 14th April 2020 Wednesday 15th April 2020 Thursday 16th April 2020 Tuesday 21st April 2020 Wednesday 22nd April 2020 Thursday 23rd April 2020 Tuesday 7th July 2020 Wednesday 8th July 2020 Thursday 9th July 2020 Tuesday 14th July 2020 Wednesday 15th July 2020 Thursday 16th July 2020 Tuesday 6th October 2020 Wednesday 7th October 2020 Thursday 8th October 2020 Saturday 19th December 2020 Monday 21st December 2020 * 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 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 CVV Code Cardholder Name Comments/Questions This iframe contains the logic required to handle Ajax powered Gravity Forms.