Name: ______________________________   Social Security #: _____________________ 

Address:  ________________________City: _____________  State: _____ Zip: ________ 

School Address: __________________  City:  _____________ State: _____ Zip:  ________ 

School Phone #:  ______________________    Permanent Phone #: ___________________ 

E-mail Address:  ______________________  Cell Phone:  __________________________ 

ParentÕs Work Phone   Mom: ________________________  Dad: ____________________

ParentÕs Cell #Õs:  _________________________________________________________

Person(s) to call in case of emergency if parent cannot be reached:   

Name:  ________________________  Relationship:________________ #: ____________

Please answer the following questionnaire:

1. How long have you been riding? ___________________________________________

2. How long have you been riding under instruction? ___________________________

3. Please describe your own riding experience (showing, pony club, etc.)

____________________________________________________________________

____________________________________________________________________

_____________________________________________________________________

4.  Have you ever worked at an equestrian camp before?  Explain and list name of camp, dates, 
      person to contract and phone number.

__________________________________________________________________

_____________________________________________________________________

5.  Have you been in leadership roles with younger youth other than equine camp?  (Scouts, 4-H,
 other camps,etc)  If so, please explain and list name of camp(s), dates, and person to contact and
 phone number(s)._________________________________________________________

______________________________________________________________________

6.  Please explain your goals for the summer.  What would you like to gain from working at
 Zion FarmÕs Equestrian Camp?

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

7.  Please list your special qualifications/certifications (CPR/First Aid/Lifeguard/etc)

________________________________________________________________________

________________________________________________________________________

____________________________________________________________

8.  Reference:  Please list names, addresses and phone numbers of 3 persons(no family members)
 ie: riding instructor/coach, professor/teacher, and other

1.       ____________________________________________________________________

2.       ____________________________________________________________________

3.       ____________________________________________________________________

Health :

1.  Describe any allergies or limitations that Zion Farms should be aware of while you
are at Zion Farms:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________     

2.  Are you on medication of any kind?

 ______________________________________________________________________

_______________________________________________________________________

Please place a ÒTÓ before those activities you can organize and teach and an ÒAÓ for 
those activities in which you can assist:

If you are under the age of 21, please have your parent or guardian sign where applies:

1.   Will you be bringing a car to Zion Farms?  ___________

2.   Do you give your child permission to leave Zion Farms property during designated hours in his/her car?  Explain:

________________________________________________________________________________________

Parent Signature:____________________________________ Date:________________

3.        If your child does not have a car at Zion, do you give your child permission to ride off property during
 designated hours with another Staff.

______________________________________________________________________________________

Parent Signature: __________________________________  Date: _______________

I understand that, if employed, I will be an at-willed employee unless there is an agreement or law, which alters
 that status.  Furthermore, I understand that any agreement must be in writing and signed by the designated camp
 official.  If also understand that untrue, misleading, or omitted information herein completed by the applicant may
 result in dismissal, regardless of the time of discovery by the camp.

____________________________________________                       ____________
 Signature                                                                                                Date
 

This page Copyright Zion Farms

email : general@zionfarms.com

2979 Big Texas Valley Rd. NW Rome, Georgia 30165
P.O. Box 860 Armuchee, Georgia 30105
706-235-8002     706-232-4323