Ride The Trail.
Discover Your Path.
Get Into Geerz.

Family Registration: 2022-2023 Season USA

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Welcome Aboard!


1. Please note that completing this registration form is absolutely mandatory for attending any geerz riding sessions.

2. Please note that registration does not guarantee your child a spot, as groups fill up quickly. We will make every effort to accommodate all families.

3. For further information, click here.

IF:

(1) You are a returning family from last year;

OR

(2) You are a family who signed up this year
and wishes to register an additional child,

THEN:

Please enter your email here:


Parent Info

*Family Type
 
Orange fields required. Leave others blank, unless different from parent 1
 

Parent / Guardian 1

Parent / Guardian 2

*Parent / Guardian Type
*First Name
*Last Name
*Email
*Mobile Phone
Area code    Phone
*Do you have WhatsApp?
*Preferred Language
Family Situation
Any additional family circumstances we should be aware of. All information will be treated with the highest level of confidentiality.

Contact Information

Home Phone
Area code    Phone
Fax
Website
*Mailing Address
*City
*Zip/Postal Code
*Emergency Contact Person
Please enter someone other than the participant's parents
*Emergency Contact Phone
Area code    Phone
*Relationship to Participant

Scheduling Preferences

Top Preference
Day:     Time: :
Second Preference
Day:     Time: :
Day:     Time: :

General Information

*May we use your children's photos for publicity?
Geerz relies on the generosity of our donors to make our program available to hundreds of needy kids. Pictures play a big role in this.
*HMO
*Policy Number
General Comments
Please enter here any general information about your *family* that you'd like us to be aware of.

Information About Your Children

Child # 1

 
*First Name
*Gender
*Date of Birth
Child must be at least 7 by the start of the coming year. When using the calendar feature, be sure to click on the day.
*School
*Grade for the school year 2022-2023
*Shirt Size
*Child's Medical Health Card
*Does your child have any medical conditions we should be aware of?
This confidential information will be shared with the instructor and ride coordinator alone.
*Please specify
*Does your child suffer from allergies?
*Please specify
Any requests that your child be grouped with friends?
Comments
Please enter here any general information about your *child* that you'd like us to be aware of.

Child # 2

 
*First Name
*Gender
*Date of Birth
Child must be at least 7 by the start of the coming year. When using the calendar feature, be sure to click on the day.
*School
*Grade for the school year 2022-2023
*Shirt Size
*Child's Medical Health Card
*Does your child have any medical conditions we should be aware of?
This confidential information will be shared with the instructor and ride coordinator alone.
*Please specify
*Does your child suffer from allergies?
*Please specify
Any requests that your child be grouped with friends?
Comments
Please enter here any general information about your *child* that you'd like us to be aware of.

Child # 3

 
*First Name
*Gender
*Date of Birth
Child must be at least 7 by the start of the coming year. When using the calendar feature, be sure to click on the day.
*School
*Grade for the school year 2022-2023
*Shirt Size
*Child's Medical Health Card
*Does your child have any medical conditions we should be aware of?
This confidential information will be shared with the instructor and ride coordinator alone.
*Please specify
*Does your child suffer from allergies?
*Please specify
Any requests that your child be grouped with friends?
Comments
Please enter here any general information about your *child* that you'd like us to be aware of.

Child # 4

 
*First Name
*Gender
*Date of Birth
Child must be at least 7 by the start of the coming year. When using the calendar feature, be sure to click on the day.
*School
*Grade for the school year 2022-2023
*Shirt Size
*Child's Medical Health Card
*Does your child have any medical conditions we should be aware of?
This confidential information will be shared with the instructor and ride coordinator alone.
*Please specify
*Does your child suffer from allergies?
*Please specify
Any requests that your child be grouped with friends?
Comments
Please enter here any general information about your *child* that you'd like us to be aware of.

Sign Up Additional Children

*How many [new ]children are you signing up?

Child # 1

*First Name
*Gender
*Date of Birth
Child must be at least 7 by the start of the coming year. When using the calendar feature, be sure to click on the day.
*School
*Grade for the school year 2022-2023
*Shirt Size
*Child's Medical Health Card
*Does your child have any medical conditions we should be aware of?
This confidential information will be shared with the instructor and ride coordinator alone.
*Please specify
*Does your child suffer from allergies?
*Please specify
Any requests that your child be grouped with friends?
Comments
Please enter here any general information about your *child* that you'd like us to be aware of.

Child # 2

*First Name
*Gender
*Date of Birth
Child must be at least 7 by the start of the coming year. When using the calendar feature, be sure to click on the day.
*School
*Grade for the school year 2022-2023
*Shirt Size
*Child's Medical Health Card
*Does your child have any medical conditions we should be aware of?
This confidential information will be shared with the instructor and ride coordinator alone.
*Please specify
*Does your child suffer from allergies?
*Please specify
Any requests that your child be grouped with friends?
Comments
Please enter here any general information about your *child* that you'd like us to be aware of.

Child # 3

*First Name
*Gender
*Date of Birth
Child must be at least 7 by the start of the coming year. When using the calendar feature, be sure to click on the day.
*School
*Grade for the school year 2022-2023
*Shirt Size
*Child's Medical Health Card
*Does your child have any medical conditions we should be aware of?
This confidential information will be shared with the instructor and ride coordinator alone.
*Please specify
*Does your child suffer from allergies?
*Please specify
Any requests that your child be grouped with friends?
Comments
Please enter here any general information about your *child* that you'd like us to be aware of.

Child # 4

*First Name
*Gender
*Date of Birth
Child must be at least 7 by the start of the coming year. When using the calendar feature, be sure to click on the day.
*School
*Grade for the school year 2022-2023
*Shirt Size
*Child's Medical Health Card
*Does your child have any medical conditions we should be aware of?
This confidential information will be shared with the instructor and ride coordinator alone.
*Please specify
*Does your child suffer from allergies?
*Please specify
Any requests that your child be grouped with friends?
Comments
Please enter here any general information about your *child* that you'd like us to be aware of.

Acceptance of Waiver

 
After reading and indicating your agreement with the Waiver, please enter your name. This is your electronic signature to your acceptance of our Waiver.
 I agree with the  Geerz Waiver and Release
*Parent 1 Name
*Parent 2 Name

Price

 
Although the actual cost to Geerz per child for the Geerz professional therapeutic program is $600, the program is heavily subsidized thanks to the generosity of our donors, and Geerz participants enjoy our quality program, with a price to you the parent similar to other after-school programs in your city.
Amount Due
Amount will appear when you select city   
Amount paid to date
$
Balance due
$

Discount

 
Discounts are available for families experiencing financial hardship. Please read the conditions to see if you qualify.
*I would like to request a scholarship
*Scholarship Amount Requested $
 

Payment

*I will pay now online
*Card Type
*Card Number
*Verification Code
*Expiration Date
   
*Cardholder's First Name
*Cardholder's Last Name