Application - Page 3 of 3

PARENT INFORMATION

    Parent or guardian, please read all the rules and regulations with your child. Fill out this form and sign the waiver at the end. This form must be completed before your child can be a Ponyland Volunteer.

Child's name:____________________________________

Child's date of birth:_______________________________

Mother's name:___________________________________

Father's name:____________________________________

Address:________________________________________

Home phone:_____________________________________

Emergency Phone number:___________________________

Medical Information

Does your child have any allergies or medical condition that I need to be aware of? ___________________________________________________

Name of Pediatrician:_________________________________________

Phone number:_______________________________________________

I ______________________________ (print parent's name) have read and understand all the rules and regulations of Ponyland. I also understand safety is a priority at Ponyland. In the event of an accident, I will not hold Ponyland responsible. In the unlikely event an accident does occur, I authorize the officails of Ponyland to give permission to any physician, nurse or hospital normal emergency medical care as they deem necessary in the interest of my child.

Parent or Guardian (Please print name) ___________________________

Signature of parent or guardian:__________________________________

Relationship to child:__________________ Date signed:______________

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