Registration Form
Date
*
-
Month
-
Day
Year
Date
Child's Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Child's Age (At time of Camp)
*
Child's Grade for 2023 School Year
*
Shirt Size
*
Youth Small
Youth Medium
Youth Large
Youth X-Large
Name of Custodial Parent/Guardian
*
First Name
Last Name
Address of Custodial Parent/Guardian
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of Custodial Parent/Guardian
*
Please enter a valid phone number.
Medical Information: Please list any medications, allergies, and/or medical conditions. **Vosburgh Farm will not be responsible for administering any medications**
*
Insurance Acknowledgment: I acknowledge that my child will be participating in supervised physical activity where inherent risk is involved. Also, I understand that Vosburgh Farm and Kesicke Farm does NOT carry insurance for program participants. Please sign below.
*
Clear
Pick-Up Release Information: Please provide Name, Relationship, and Phone Number of persons permitted to pick up your child from the program.
*
Week(s) signed up for:
*
July 10-14
July 17-21
July 24-28
July 31-Aug 4
Aug 7-11
Aug 14-18
Submit
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