Farm Camp

For questions and concerns please contact us at msfplaces@gmail.com or call us at 603-783-5159.

Name of Camper

First NameLast Name

Age:

Age:DOB:School Grade:

Phone Number

Area CodePhone Number

Email*

Print Parent name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Tetanus Shot Date:

List of Allergies/Food Intolerance:

List medications your child needs to take at camp, dosage, and when it is to be taken:

Physician Information:

Physician's name:Phone:

Is there anything you would like to share about your child that will help us give them an excellent camp experience?

Authorization for Emergency Medical Treatment:

“I, the parent (or guardian) of the above-named camper, do hereby give
permission to the Learning Networks Foundation and Miles Smith Farm staff to secure medical treatment for my child if necessary. I also understand that there may be some risk of injury associated with participation in the day camp and I agree to waive any and all claims of liability, release and hold harmless Learning Networks Foundation and Miles Smith Farm Camp, its owners, employees, and volunteers, in the event that such injury may occur to my child."

Print name of parent:

Signature

Miles Smith Farm

56 Whitehouse Road, Loudon NH 03307