Circle K Ranch Connections Summer Registration

Parent or Legal Guardian*

Please use this space to provide contact information of parent or legal guardian.

First Last

Relationship to Participant

Please state your relationship to the youth participant if not parent.

Email*

Contact Number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name/Age/Height/Weight/ any Allergies of Participant(s)*

Allergies and/or food sensitivities.

Please Express Your Interest

Tell us a little about yourself and why our Circle K Ranch Connection Programs Interest you?

Please Select Event/s You are Registering For

Saturday S.M.I.L.E.S. 6 Week Mentorship Package

Open to ages 6 and up. From 9:45 AM-1:00 PM.

Saturday S.M.I.L.E.S. 6 Week Package

*Please Note*

Saturday S.M.I.L.E.S. Cost is based on a 6 week mentorship package. There will be no reimbursement for a date missed. If unable to attend one of the dates please list below:

Brave Horse Kids

Please Select which Dates you will be attending. This is open to youth ages 6-17. From 12:30 PM-3:00 PM

Brave Horse Kids June 3rd
Brave Horse Kids June 17th
Brave Horse Kids July 8th
Brave Horse Kids July 15th
Brave Horse Kids July 29th
Brave Horse Kids August 5th
Brave Horse Kids August 19th

General Waiver/Horse Rental and Liability Release*

Attached you will find the Circle K Ranch General Waiver and Horse Rental and Liability Release.
I understand that these Forms are required for every participant and legal guardian/parent. That without these forms signed by the legal guardian/parent either participants youth and adult alike will be unable to attend.

I understand these forms are required for youth participant as well as legal guardian/parent participant.

Payment

Scholarship Applications available, Please complete the Scholarship Application located on our webpage and a member of our team will connect with you.

Saturday S.M.I.L.E.S. 6 Week Mentorship

Includes 6 week Mentorship Program for One adult and One youth, Lunch and Summer End Overnight Camp Out. ($700 for each additional youth participant. Add below) Please notate in comments section if you would like to apply for a scholarship.

Price: $950.00

Saturday S.M.I.L.E.S.- Additional Youth

Price: $700.00

Ages 6-17

Name/s and Age/s of Each Additional Youth Participant

Brave Horse Kids

Includes a Circle K Ranch mentor, their own personal horse for the duration of Brave Horse Kids as well as a picnic Lunch. $75pp. Per Session Date. Please Notate in Comments section below if you are interested in applying for a scholarship.

Price: $75.00

In Case of an Emergency

Emergency Contact*

First Last

Phone*

Medical Insurance Carrier and Member ID#*

EX. Blue Cross Blue Shield KAI5555555

Medical Consent*

I as the responsible party for minor(s) participant. In cases of emergency, I further consent to the examination or treatment of participant by a
physician duly licensed to practice medicine in the United States of America or any health care
professional duly licensed to provide heath care serviced in the United States of America for
medical care and services deemed necessary by the doctor, its agents, servants, and
employees. I give permission to the doctor or health care professional to provide any and all
medical care they deem, in their professional opinion, to be necessary. I agree to pay for any
and all medical expenses incurred as a result of the use of this consent.
I acknowledge by typing my name in this document, that if anyone is hurt or property is damaged during
my child’s participation in these activities, I may be found by a court of law to have waived my
right to maintain a lawsuit against The Circle K Ranch and Ranch Connections on the basis of
any claim form which I have released them herein. I agree that if any portion of this agreement
is found to be void or unenforceable, the remaining portions remain in full force and effect. I
have fully informed myself to the contents of this PARENTAL/GUARDIAN AUTHORIZATION, CONSENT and RELEASE by reading it before I checked consent box.

I give consent to medically treat my minor(s)

Thank You For Registering

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Notes: Please use for additional notes. Ex. Payment type, amount, date of payment, Scholarship applied if applicable etc

Phone

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Circle K Ranch Connections Registration Form

Please Select Event/s You are Registering For

Payment

In Case of an Emergency

Thank You For Registering