Name: Shopping Extravaganza
Start: 2023-09-09T10:00:00-06:00
End: 2023-09-09T18:00:00-06:00
Location: Outlets at Castle Rock

Which week of Summer Camp are you Signing up for?

Camper's Name

First

Last

Camper's Address

Address Line 1

City

State

Zip Code

Additional Camper Information

Date of Birth

Gender

Weight (lbs)

Height (ft' in'')

T-Shirt Size (unisex)

Youth Small
Youth Medium
Youth Large
Youth XL

Signature Describe Mobile

Parent/Guardian Information

Relationship to Camper

Name

First

Last

Preferred Contact Method:

Address

Address Line 1

City

State

Zip Code

Preferred Phone Number

Mobile Phone

Home Phone

Work Phone

Email

How did you hear about StableStrides?

Emergency Contact Information

Provide emergency contact information other than the primary parent or guardian previously listed. Note, in the event of a medical emergency, it is StableStrides policy to call 911.

Emergency Contacts Name

First

Last

Relationship to Camper

Phone

Seizures:

Yes
No

Allergies:

List N/A if none

Medications:

List N/A if none.

Camper Health History

Check the box next to any current or past health issues that apply. If one or more boxes is checked please provide details in the description box.

Describe any health issues selected above:

2026 Summer Camp Participant Policies

We kindly ask campers, parents, and caregivers to please take a few minutes to review the following policies and guidelines relating to participation and eligibility in the program and sign that it has been reviewed. Any questions can be directed to 719-495-3908 or connect@stablestrides.org

Attendance

If your child is unable to attend their scheduled week of camp or is sick for a day, notification must be made by calling StableStrides at 719-495-3908 as soon as the absence is anticipated so we may provide sufficient notice to staff and volunteers. There is no make-up opportunities for missed sessions unless StableStrides cancels due to unforeseen circumstances.

Payment and Paperwork

Camp weeks are prepaid and secure your camper’s placement with full payment for your desired week of camp. Cancellation policy: If a camper cancels more than 30 days before camp starts, their tuition minus a $25 processing fee will be returned. If a camper cancels with less than 30 days notice, their tuition minus a $50 processing fee will be returned, only if another camper fills the spot.

Attire

Campers should dress in weather-appropriate clothing and always wear long pants (even during summer) made of non-slippery material, with sturdy-soled boots or shoes with a ¼” heel for riding. A change of clothes for non-riding activities is encouraged for hotter days. Pre-applied sunscreen and bug spray are recommended.

Riding Equipment and Safety Policy

All campers must wear an ASTM/SEI approved riding helmet when riding or working around horses while at StableStrides. StableStrides provides a riding helmets for all participants. StableStrides saddles are equipped with safety stirrups and hand holds. Outside food and beverages are not allowed in the arena area.

Pick-up/Drop-off

Pick up and drop off for camp will be by the front doors of StableStrides riding arena. If you will be late for pick-up, please provide us with as much notice as possible so we can have staff/volunteers avaialbe to wait with your child. Please observe the 5 mph speed limit when arriving and leaving.

Riding Participation Criteria

Physically able to sit symmetrically with torso upright and legs astride the horse during dynamic movement
Physically able to maintain head and neck position independently in proper alignment with dynamic movement
Weigh less than 150 pounds
Able to sit independently without sidewalker support
Does not exhibit physical or behavioral conditions that are contraindicated by PATH Intl. (see Physician’s Statement)
Have current signed and dated paperwork – including Registration and Release Forms, Physician’s Statement
Able to tolerate a riding safety helmet
Ability to accommodate the movement of the horse without pain
Adequate range of motion in hip(s) to sit astride
Safety awareness around animals
Ability to express pain or discomfort
Behave in a manner that is safe for self, horses, and others

Signature

Clear Signature

I agree to all of the above policies for my child

Authorization to be Photographed and/or Interviewed

Photo/Interview Authorization

I Do
I Do Not

I hereby authorize StableStrides and its affiliated facilities, agents, contractors, providers or associates to interview and/or take photographs of me. I understand that the term photograph may include, but not be limited to, videotape, videodisc, digital image and any other mechanical means of recording or producing visual images (hereinafter referred to as photographs). I also understand the interview session may involve, but not be limited to, audio tape, or other recording device, written recording or other mechanical means or medium to preserve the discussions (hereinafter referred to as interview material).

First Name Use Authorization:

I Do
I Do Not

I hereby authorize StableStrides to use my first name in association with photographs and/or interviews.

Reason for Participation:

I Do
I Do Not

I hereby authorize StableStrides to disclose my disability or reason for participation at StableStrides in association with photographs and/or interviews.

I understand and agree that the photographs and/or interview material may also be used and/or disclosed for any and all other purposes deemed appropriate by, StableStrides and its affiliated facilities, agents, contractors, providers or associates. Such purposes may include, but not be limited to, education, treatment, internal marketing (for example, photo displays within the facility), public relations, advertising, communication materials, promotional and marketing publications (including postings on an organization’s website), and/or fundraising activities.

I understand that I may refuse authorization and that my refusal will not affect my ability to obtain treatment, payment, enrollment in any health plan, or eligibility for benefits. I understand that I may revoke this authorization at any time in writing by contacting the StableStrides Office Manager.

I agree to hold StableStrides and its affiliates, agents, officers, contractors, providers, directors, and associates, or designated third parties who are involved in the production, duplication, publication or any other use and/or disclosure of the photographs, and/or interview material harmless for any damages incurred by such use and/or disclosure of the photographs and/or interview material. I also understand that the photographs and/or interview material used and/or disclosed pursuant to this authorization may be re-disclosed by a recipient and can no longer be protected by the aforementioned parties.

In addition, I waive all rights to or conditions on the use and/or disclosure of these photographs and/or interview material that I may have pursuant to this authorization and for the consideration provided, I further waive any claim for payment or royalties related to the production, duplication, publication or other specified use and/or disclosure of such by StableStrides and/or any affiliated facilities, or any other party involved in the specified use and/or disclosure now or in the future.

Parent/Guardians Signature

Clear Signature

Acknowledgment of Risk and Acceptance of Service

I am aware of the risks of contracting or spreading communicable diseases while working or volunteering at StableStrides; attending an event; and/or receiving face-to-face services from StableStrides during the time of a communicable disease outbreak. I understand that participating in services at StableStrides during such an outbreak enhances risks and uncertainties, including, without limitation, an increased likelihood that I, and/or those with whom I interact, contracts and/or transmits the disease. StableStrides has taken all the necessary, precautionary measures possible, in accordance with governmental agencies and the Center for Disease Control (CDC), but the risk of a communicable disease cannot be fully mitigated. The Undersigned Person understands this risk, agrees that such risks cannot be eliminated and expressly assumes all associated risks which remain.

I agree to and will strictly follow all federal, state, and local guidelines to protect against communicable disease health risks. This may include, but is not limited to, waiting in my vehicle and/or home until I am asked to enter a building; maintaining social distance; washing my hands prior to and following each session or activity; use of hand sanitizer upon request; wiping down surfaces with disinfecting wipes and/or wearing a protective masks and/or gloves.

I agree to stay home and/or cancel my services should I have personally exhibited or have been in contact with someone who has presented with illness within the previous 14 days, including; cough, sneezing, fever, chest congestion, or additional signs of potential spread of any virus or bacteria/disease. In addition, I will follow the recommendations of my provider once I have notified them of these risks in regards to my future services or attendance during this pandemic.

I am signing under my own free will, and agree to follow these guidelines and hold harmless all individuals associated with or through my services acquired from StableStrides.

Parent/Guardians Signature

Clear Signature

BY SIGNING ABOVE, I CONFIRM THAT I HAVE READ AND UNDERSTAND THIS DOCUMENT.

HIPAA Notice of Privacy Practices Statement

Notice of Information Practices and Privacy Statement for StableStrides

How We Collect Information About You: StableStrides and its employees and volunteers collect data through a variety of means including but not necessarily limited to letters, phone calls, emails, voice mails, and from the submission of applications that is either required by law, or necessary to process applications or other requests for assistance through our organization.

What We Do Not Do with Your Information: Information about your financial situation and medical conditions and care that you provide to us in writing, via email, on the phone (including information left on voice mails), contained in or attached to applications, or directly or indirectly given to us, is held in strictest confidence.

We do not give out, exchange, barter, rent, sell, lend, or disseminate any information about applicants or clients who apply for or actually receive our services that is considered patient confidential, is restricted by law, or has been specifically restricted by a patient/client in a signed HIPAA consent form.

How We Do Use Your Information: Information is only used as is reasonably necessary to process your application or to provide you with health or counseling services which may require communication between StableStrides and health care providers, medical product or service providers, pharmacies, insurance companies, and other providers necessary to: verify your medical information is accurate; determine the type of medical supplies or any health care services you need including, but not limited to; or to obtain or purchase any type of medical supplies, devices, medications, insurance,

If you apply or attempt to apply to receive assistance through us and provide information with the intent or purpose of fraud or that results in either an actual crime of fraud for any reason including willful or un-willful acts of negligence whether intended or not, or in any way demonstrates or indicates attempted fraud, your non-medical information can be given to legal authorities including police, investigators, courts, and/or attorneys or other legal professionals, as well as any other information as permitted by law.

Limited Right to Use Non-Identifying Personal Information from Biographies, Letters, Notes, and Other Sources: Any pictures, stories, letters, biographies, correspondence, or thank you notes sent to us become the exclusive property of StableStrides. We reserve the right to use non-identifying information about our clients (those who receive services or goods from or through us) for fundraising and promotional purposes that are directly related to our mission.

Clients will not be compensated for use of this information and no identifying information (photos, addresses, phone numbers, contact information, last names or uniquely identifiable names) will be used without client’s express advance permission.

You may specifically request that NO information be used whatsoever for promotional purposes, but you must identify any requested restrictions in writing. We respect your right to privacy and assure you no identifying information or photos that you send to us will ever be publicly used without your direct or indirect consent.

Parent/Guardians Signature

Clear Signature

BY SIGNING ABOVE, I CONFIRM THAT I HAVE READ AND UNDERSTAND THIS DOCUMENT.

Release and Indemnity for Equine Activities

WARNING: UNDER COLORADO LAW, AN EQUINE PROFESSIONAL IS NOT LIABLE FOR AN INJURY TO OR THE DEATH OF A PARTICIPANT IN EQUINE ACTIVITIES RESULTING FROM THE INHERENT RISKS OF EQUINE ACTIVITIES, PURSUANT TO SECTION 13-21-119, COLORADO REVISED STATUTES.

In consideration of being permitted to participate in equine activities at the StableStrides, the undersigned participant freely and voluntarily agrees for me, my spouse, heirs, successors, personal representatives and assigns to the following:

1. I release and Discharge Acts 19:11, dba StableStrides from any and all liability, claims, demands or causes of action whatsoever arising out of any damages, loss or injury to me or to my property while I am participating in any equine activities and/or while I am engaged in any activity during the period of participation in an equine activity, whether such loss, damage or injury results from the negligent acts or omissions of StableStrides or from any other cause.

2. I acknowledge that participation in equine activities involves a certain amount of risk and I accept and assume any and all risks and dangers of bodily injury, disability, death and/or property damage, even if caused in whole or in part by the negligent acts or omissions of StableStrides, or from any other cause.

3. I indemnify and hold harmless StableStrides from any and all loss, liability or expense of any nature whatsoever, including reasonable attorney’s fees and costs, which it may incur or be exposed to as a result of any claim or bodily injury, death or property damage resulting from my participation in any equine activity.

4. I agree that exclusive jurisdiction and venue for any lawsuit arising out of this Agreement or the dealings between us shall be in the state courts in El Paso County, Colorado, and that the laws of the State of Colorado shall apply.

5. To the extent that any part of this Agreement is found to be invalid, void or illegal under applicable law, then the Court shall reform such part of this Agreement only to the extent necessary in order to make it enforceable, and all of the remainder of this Agreement shall remain in full force and effect.

6. Definitions.

a. All references to “StableStrides” in this document shall refer to Acts 19:11, dba StableStrides, as well as its successors, assigns, officers, directors, employees, agents, insurers, instructors and independent contractors performing services at StableStrides.

b. Equine Activity. For purposes of this document, the term “equine activity” shall include any activity in which I engage while participating in therapeutic horseback riding, equine assisted activities (such as equine assisted learning and equine assisted psychotherapy) or hippotherapy classes at StableStrides, as a participant. The term shall also include activities in which I engage in order to prepare the horses, equipment, facilities or clients for use in therapeutic horseback riding, equine assisted activities and hippotherapy classes. The activities in which I may engage include, but are not limited to, shoveling stalls, cleaning and storing tack, maintaining equipment and facilities, grooming, tacking and untacking, bringing horses in from the turnout, returning horses to their stalls, feeding and watering horses. Although most of these activities will occur on site at StableStrides’ facilities located at 13620 Halleluiah Trail, Elbert, CO 80106 or 1035 Lower Gold Camp Road, Colorado Springs, CO 80905, the term equine activity also includes any activities in which I engage, as a participant, at off site events in which StableStrides participates or sponsors. I understand and agree that my participation in an equine activity begins upon my arrival at the place where the equine activity begins, then stops upon my departure from the place where the equine activities end.

c. Term of Release and Indemnity. The Release and Indemnity for Equine Activities shall be binding for a period of time equal to the longest statute of limitation, regardless of the theory of law, applicable to any claim arising out of or in any way connected with the undersigned’s participation in an equine activity.

MY SIGNATURE BELOW INDICATES THAT I HAVE READ THIS ENTIRE DOCUMENT, UNDERSTAND IT COMPLETELY AND VOLUNTARILY AGREE TO BE BOUND BY ITS TERMS.

Parent/Guardians Signature

Clear Signature

Optional Demographics Information

We often receive requests for demographic data when applying for grants and other funding. If you are willing to contribute information, we would greatly appreciate it.

Race

Ethnicity

Military Status

Household Income

Branch of Military (if applicable):

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Payment Information:

Payment is required at registration to ensure your spot is secure.

One Week of Leadership Camp

Camper Fees - $350.00
I will cover the Processing Fees of $12 - $12.00

Coupon

Total

Item Quantity Qty Total

There are no products selected.

One Week of Leadership Camp - Camper Fees 1 $350.00

One Week of Leadership Camp - I will cover the Processing Fees of $12 1 $12.00

Subtotal

Total $362.00

Payment Options

Card Number

Expiration Date

Security Code

Card Holder Name

September 2023