| Camper's Name |
|
| Age |
|
| Social Security Number |
|
| Female |
|
| Male |
|
| Birthdate |
|
| Name of Parent/Guardian |
|
| Street Address |
|
| City |
|
| State |
|
| Zip |
|
| Home Phone |
|
| Cell Phone |
|
| Work Phone |
|
| Email |
|
Select
Camp Dates
Full & partial scholarships are available.
Call 636-8171. |
Pre-School Camp
(4 & 5 year olds)
Full Price: $80 (Min. $35 deposit at checkout) |
|
Junior Camp
(1st to 3rd graders)
Full Price: $150 (Min. $75 deposit at checkout) |
|
Discovery Camp
(4th to 6th graders)
Full Price: $170 (Min. $85 deposit at checkout) |
|
| Farm Day Camp
fee includes a T-shirt! Please provide your child’s size! |
| Select T-Shirt Size |
|
Emergency
Information
If I am not available for
an Emergency, Please Notify: |
| Name |
|
| Phone Number |
|
| Alternate Name |
|
| Alternate Phone Number |
|
| Preferred Medical Facility |
|
Health
History
(check all that apply) |
| Frequent Ear Infections |
|
| Heart Condition |
|
| Diabetes |
|
| Bleeding/Clotting Disorder |
|
| Asthma |
|
| Hypoglycemia |
|
| If any above are checked,
please enter here all relevant information which may be needed by a
medical practitioner. |
|
| Are there any other medical
conditions that the staff of Rural Resources Farm Day Camp should be
aware of during your child’s stay at Farm Day Camp? |
|
| Check if camper
is allergic to any of the following: |
| Insects |
|
| Food |
|
| Animals |
|
| Plants |
|
| Medicines |
|
| Other Allergies |
|
| If any items above were
checked, please specify the cause of the allergy, signs of the allergic
response and the treatment given |
|
| Name of Family Physician |
|
| Family Physician's Phone
Number |
|
| Do you carry family medical
insurance? |
|
| If so, indicate
name, policy number and carrier |
|
| Is there any other
information about your child that you would like the staff of the Rural
Resources Farm Day Camp to be aware of in order to give your child a
personal and quality Farm Day Camp experience? |
|
This health
history is correct so far as I know, and the person herein described has
permission to engage in all camp activities except as noted above. |
| Please enter your name here
to affirm |
|
MEDICAL
AUTHORIZATION AND RELEASE/PHOTO RELEASE
Should my child sustain or incur any accident or illness while
attending programs sponsored by the Rural Resources Farm Day Camp, and
attempts to contact myself or emergency contact fail, I hereby
authorize the Rural Resources Farm Day Camp staff to execute any and
all documents on my behalf including necessary releases, which might be
required by a medical facility to perform emergency care. I understand
that Rural Resources may use photographs and/or video tapes of my child
for public relations. |
|
Please enter your name here to affirm |
|
