Name: Coffee & Conversation
Start: 2023-04-12T09:00:00-07:00
End: 2023-04-12T09:00:00-07:00
Location: MMS Upper Campus Assembly Room

Step 1 of 2

Parent/Guardian
Name:*
First Last
Relationship*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Does the child live at this address:*
- Full time?
- Part time?
Home Phone
Cell Phone
Work Phone
Email*
Parent/Guardian
Name:
First Last
Relationship:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Does child live at the address:
- Full time
- Part time
Home Phone
Cell Phone
Work Phone
Email
Emergency Contacts
In addition to parents, to be called in case of emergency (must be 18 years of age or older)
Name*
First Last
Relationship:*
Phone*
Name
First Last
Relationship:
Phone
Medical Information
Family Doctor
Doctor's Phone
Dentist
Dentist's Phone
Is your child on any regular medication?*
- Yes
- No
If YES, please specify:*
Allergies?*
Any religious objections or exemptions to medical treatment?*
- Yes
- No
Legally, parents must give their written permission to MMS staff to dispense any form of medication. I authorize MMS staff to give my child the following:
- Aloe Vera/Sun relief
- Antihistamine
- Chewable Antihistamine
- Hydrocortisone Cream
- Topical sting relief
- Poison oak wash/lotion
- Sunblock
- Acetaminophen
- Chewable Acetaminophen
- Ibuprofen
- Aspirin
- Throat Lozenges
- Other
Specify:*
Date of last tetanus shot*
Please list any conditions which may require action (allergies, bee stings, asthma, diabetes, etc.)
In the case of most medical occurrences, parents or emergency contacts will be called to decide how to proceed. However, in the case of an emergency that requires immediate response:*
I authorize MMS staff to arrange transportation to the nearest hospital in case of accident or acute illness and to arrange for possible emergency and/or surgical care under whatever conditions necessary to preserve the life, limb, or well-being of my child.
- Yes
- No
Is there any other important information we should know that will help us care for your child?
Medical Insurance Information
Name on Insurance Policy
Insurance Carrier
ID# of Policy Holder
Group #
Effective Date
Phone # of Carrier
Carrier Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Permissions
I authorize MMS staff to arrange field trips and supervised walks during the school day on the MMS property. I understand my child will return to MMS by regular dismissal time unless notified otherwise.*
- Yes
- No
I authorize MMS to publish my child's photo, and/or video for school advertising purposes online or in print. No name will be attached to pictures or videos.*
- Yes
- No
Horse Program Information
You have chosen to enroll your child in a horse camp or program. Please read the Mt. Madonna Stables liability waiver and fill out the following fields.
Child's Height*
Child's Weight*
Horse Handling/Riding Experience*
- 1st Time Rider
- Less than 50 hours of lessons
- More than 50 hours of lessons
Does this child have any physical or mental conditions that may affect his/her safety and ability to ride, drive, and/or train horses?*
- Yes
- No
If "yes", how can we help this student with his/her special needs?*
Please refer to the PDF waiver to agree to the following.*
I understand that checking the following boxes constitutes a legal signature confirming that I acknowledge and agree to the Terms of Acceptance included in the Mt. Madonna Stables liabilty waiver
- Section B. Agreement, Scope, Definitions and California Jurisdication
- Section C. Inherent Risks/Assumption of Risks
- Section D. Conditions of Nature Warning, Unfamiliar and Sudden Sights, Sounds, and Movements Warning, and Inspection of Premises
- Section E. Saddle Girths/Natural Loosening Warning
- Section F. Protective Headgear/Helmet Warning
- Section G. Liability Release
Acknowledgement*
We, the parents of the above named, for and in consideration of our child's participation in all activities of Mount Madonna Stables, state that we have read the waiver, release and hold harmless agreement written above and we expressly agree that the terms and conditions of said waiver, release and hold harmless agreement shall apply to and be binding upon us and our minor child in so far as it pertains to his or her participation and to any injury or damage said minor child, or his/her horse, may sustain or cause as a result of said participation.

I/We represent that I/we have read and do understand the foregoing agreement, liability release and assumption of risk agreement, I/we understand that by signing this document I/we are giving up rights to sue today and in the future. I/We attest that all facts are true and accurate. I/We are signing this while of sound mind and not suffering from shock, or under the influence of alcohol, drugs, or intoxicants.
- I Agree and declare under penalty of perjury that the foregoing is true and correct.
Cancellation Policy:
- There is a $50 non-refundable registration fee per student.
- There is a full refund (minus $50 registration fee) if cancellation is within 3 weeks of start of the program.
- There is a 50% refund (minus the $50 reg. fee) if cancellation is within 2 weeks of registered program.
- There is no refund for cancellations within one week of the program.
- Additionally, there is a $50 non-refundable transportation fee per student if registered for transportation.
How did you hear about Mount Madonna School Summer Program?
- We are a current MMS family
- Mailer
- SC Sentinel
- The Pajaronian
- Growing Up in SC
- Morgan Hill Times
- Gilroy Dispatch
- KAZU Radio
- Mount Madonna Center
- Friend or Family
- Other
Please specify:
Promotional Code
Total
$0.00
Billing Address*
Street Address Address Line 2 City State ZIP Code
Billing Email*
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

Mount Madonna School

Preschool through 12th grade education

Summer on the Mountain Registration for Waitlisted Campers

Step 1 of 2

Select a camp and week(s) to attend

Mountain Explorers

Redwood Explorers

The Redwoods on Horseback

Parent/Guardian

Parent/Guardian

Emergency Contacts

Medical Information

Medical Insurance Information

Permissions

Horse Program Information

Cancellation Policy: