Day Camps at the Bruentrup Heritage Farm Registration Form
Summer 2022
Camper's Information
Personal & Health & Contact
Name
First Name
Last Name
Birth Date
January
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Month
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Year
Age (at time of camp)
2
3
4
5
6
7
8
9
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11
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18+
Grade (entering this fall)
T-shirt Size:
Youth Small
Adult Smaill
Youth Medium
Adult Medium
Youth Large
Adult Large
Blood Type
0 RH+
0 RH-
A RH+
A RH-
B RH+
B RH-
AB RH+
AB RH-
List Any Allergies and Dietary Restrictions
Medications & Frequency
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent / Guardian Information
(All correspondence and and invoices will be sent to this person)
Name
First Name
Last Name
Email
example@example.com
Cell Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Relationship with the Camper
Emergency Contacts and Authorized Pick Up Persons
Program Information
Program & Transportation & Payment
Select Camp Week Farm-to-Table, entering grades 1-3
July 11 - 14, 9 AM - 4 PM
July 18 - 21, 9 AM - 4 PM
August 1 - 4, 9 AM - 4 PM
Select Camp Week Farm-to-Table, entering grades 4 - 6
Aug 8 - 11, 9 AM - 4 PM
Select Camp Week Hmong Language & Culture entering grades 3 - 7 (please note this is a half day camp, $80 per student)
July 18 - 21, 9 AM - 1 PM
Select Camp Week Arts on the Farm, entering grades 4 - 6
July 25 - 28, 9 AM - 4 PM
Questions or to request information on scholarship funding, email or call MAHS Executive Director, T.J. Malaskee.
Director@MaplewoodHistoricalsociety.org 612.384.5883
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Day Camp at Maplewood Area Historical Society
$
50.00
Deposit for one week of camp at the Bruentrup Heritage Farm to be applied towards total tuition of $190.00 for Farm-to-Table and Arts on the Farm Camps, $80 for Hmong Language Camp due on or before first day of camp. This deposit is only refundable should MAHS need to cancel a camp week but may be applied towards an additional open week of camp.
Total
$
0.00
Credit Card
Terms & Conditions
I, the undersigned, give permission for my child to participate in camp at the Bruentrup Heritage Farm for the days they attend. I am fully aware that to reserve a space, I must make a deposit of $50 per child per one week session and submit this registration form. I fully understand and authorize my child being photographed, video and/or audio recorded for MAHS publicity. I fully understand that my child is responsible for their possessions including daily lunch. I understand that in the event of an emergency affecting my child while participating in camp at the Bruentrup Heritage Farm, a designated employee of MAHS will attempt to contact me and inform me as soon as possible. In the event I cannot be reached, I hereby give permission for my child to be treated or hospitalized by a licensed physician or hospital selected by MAHS.
Date
-
Month
-
Day
Year
Date
Signature
Clear
Submit
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