REGISTRATION FORM for 5-week Sessions

REGISTRATION FORM for 5-week Session Registration

NAME (last) ____________________(first)______________________BIRTHDAY_________

ADDRESS_____________________________CITY___________________ZIP___________

PARENT OR LEGAL GUARDIAN________________________________________________

HOME PHONE #_____________________WORK PHONE #_________________________

EMAIL______________________________________________________________________

EMERGENCY CONTACT__________________________PHONE #____________________

NAME OF PERSON(S) ALLOWED TO PICK-UP CHILD:

____________________________________DRIVERS LICENSE #_____________________

Below, please choose your 1st choice and 2nd choice of 5-week session to attend. In the
event your 1st choice is full, we will place you in your 2nd choice. Use the online session
schedule to determine the 5-week session dates.

5-WEEK SESSION Fee is $120 per session. Payment must be received in full to ensure reservation.	_________________ 1st Choice Session Desired Class Time:_________	_________________ 2nd Choice Session Desired Class Time:_________
Amount Enclosed:____________	Check Money Order Credit Card
Signature: _____________________________________Date:______________

If paying by Credit Card select one: Visa MasterCard Discovery American Express

Name:____________________________ Card # __________________________ExDate:_____

Amount to be Charged: $_________ Signature:_______________________________________

Mail form and tuition payment (check or money order made out to Capricorn Equestrian)
to: Capricorn Equestrian, 6101 Ben Road, Sachse, Tx 75048.

© 2010 Capricorn Equestrian Center
6101 Ben Road
Sachse, TX 75048
(972) 530-1124
Chad Easterling, Owner
(972) 839-2721
Email