2025 Summer Camp Detailed Registration Form

2025 Summer Camp Registration

June 16th through the 20th, 2025 - Ages 9 through 12
Camper Information

Each camper must have a separate registration form. If you are registering more than one camper, please complete a new form for each child.
Camper's Name*

First NameLast Name
Birth Date*

MonthDayYear
What grade will your camper be entering in the 2025 to 2026 school year?*
Gender*

MaleFemale
Parent/Guardian Information
Parent/ Guardian Name*

First NameLast Name
Parent/ Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/ Guardian Phone Number*
Parent/ Guardian Alt. Phone Number (optional)
Parent/ Guardian E-mail*
example@example.com
Emergency Information
Each camper must provide at least two emergency contacts. In the event of illness or injury, the listed contacts will be notified. The parent or guardian will be considered the primary emergency contact, and a second contact is required for additional support.
Emergency Contact Name*

First NameLast Name
Emergency Contact Relationship*
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Alt. Phone Number (optional)
Emergency Contact Email*
example@example.com
Would you like to add an additional emergency contact?*

YesNo
Emergency Contact #2 Name*

First NameLast Name
Emergency Contact #2 Relationship*
Emergency Contact #2 Phone Number*
Please enter a valid phone number.
Emergency Contact #2 Alt. Phone Number (optional)
Emergency Contact #2 Email*
example@example.com
All of the below fields require an answer and will need to be completed and signed in acknowledgement in order for registration to be completed. Please make certain to read through the following questions and procedures throughouly and call us if you have any questions.
Does the camper have any allergies or medical conditions? If yes, please describe. If no, please indicate N/A below.*
Is the Camper prescribed an inhaler, an EpiPen or any other emergency medications? If yes, please explain any instructions. If no, please indicate N/A below. *
If a camper requires an EpiPen or emergency medication, it must be placed in a sealed, clear plastic bag and clearly labeled with the camper's name. Parents or guardians are responsible for handing over the EpiPen or emergency medication to the designated staff member at check-in on the first day of camp. Campers are not permitted to submit their EpiPens or medications; this must be done by a parent or guardian. All EpiPens and medications will be stored securely and returned to parents or guardians at pick-up on the last day of camp.

Inhalers will be kept with the campers belongings so the camper can access them anytime they need it.

Empowerment Farm, Inc. will not be held responsible for the disbursment of any daily medications or prescriptions. Emergency medications can be stored on site in case of emergencies only.
I agree to the terms listed above.*

Yes, I understandNo, because my camper does not require an EpiPen or Inhaler
By signing below, I acknowledge and agree to the terms outlined above regarding my camper’s need for an EpiPen, Inhaler or other emergency medications and the storage procedures implemented by Empowerment Farm, Inc. I also understand that Empowerment Farm, Inc. is not responsible for checking the expiration date or effectiveness of the EpiPen, Inhaler or any other medications. Empowerment Farm, Inc., it's affliates, volunteers and staff cannot be held liable for the administration of medications, they are kept on site for emergency use only.*

Powered by Jotform SignClear
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Empowerment Farm, Inc. during the selected camp. In exchange for the acceptance of said child’s candidacy by Empowerment Farm, Inc., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Empowerment Farm, Inc. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Empowerment Farm. including all Staff, Volunteers and affiliates, all participants, sponsoring agencies, advertisers, and, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all camp activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
By signing the below I am acknowledging that I have read and understand the above informed consent and acknowledgement.*

Powered by Jotform SignClear
Medical Release and Authorization

As the Parent and/or Guardian of the named camper, I acknowledge that Empowerment Farm, Inc. does not have a physician on staff and is not required to do so. I authorize the Empowerment Farm, Inc. Staff to provide basic first aid for minor injuries, including the administration of an EpiPen if necessary. In the event of a more serious injury or illness, the Empowerment Farm, Inc. Staff will make every effort to contact me or the listed Emergency Contacts as quickly as possible. If we are unable to reach a parent or guardian, Empowerment Farm, Inc. will contact emergency services.

I understand that children with inhalers will keep them in their bags and have access to them as needed. In the case of an emergency requiring more than basic first aid, Empowerment Farm, Inc. will contact the listed Emergency Contacts for further action.

I grant permission for Empowerment Farm, Inc. Staff, including Directors, Volunteers, and Assistants, to provide necessary emergency treatment until the camper can receive care at a medical facility.

This release is valid for the duration of the registered season and is executed of my own free will, solely for the purpose of authorizing necessary medical treatment in emergency situations to protect the health and safety of my camper."
By signing the below I am acknowledging that I have read and understand the above medical release authorization.*

Powered by Jotform SignClear
Drop Off and Pick Up Procedure

1) Regular Drop-Off (9:00 AM Start Time)
-The gate opens at 8:45 AM for campers arriving for regular camp hours.
-Early drop-offs before 8:45 AM will incur a $20 flat fee unless registered for before care.
-Campers may not be dropped off before 8:45 AM without prior registration for before care.

2) Before Care Drop-Off (8:00 AM Start Time)
-The gate opens at 7:45 AM for campers registered for before care.
-Campers not registered for before care cannot be dropped off before 8:45 AM without paying an additional fee at drop-off.

3) Check-In Process
--A parent or guardian must accompany their camper to the designated sign-in area.
-Vehicles will enter through the gate, park, and the parent/guardian will walk the camper to the check-in table.
-Parents/guardians must sign in their camper, providing their name and the name of the authorized pick-up individual.
-Campers may not check themselves in.
-Drop-offs at the gate without signing in are not permitted.
-Early arrivals should park on the right side of Garland Rd. until the gate opens. Do not form a line at the gate that blocks entry for staff and before care campers.
Pick-Up Procedure

1) Regular Pick-Up (4:00 PM End Time)
-The gate opens at 3:30 PM for the pick-up process.
-Campers must be picked up promptly at 4:00 PM unless registered for after care.

2) After Care Pick-Up (5:00 PM End Time)
The gate remains open from 3:30 PM to 5:00 PM for pick-up.
Campers registered for after care must be picked up by 5:00 PM.

3) Check-Out Process
-The individual picking up the camper must present a photo ID.
-The name on the ID must match the name listed on the morning sign-in form.
-The authorized individual must sign out the camper on the sign-out form.
-Any changes to the pick-up authorization must be made in advance by calling the camp office (239) 330-2777. Please save this number in your phone or contacts for future refrence.
-Call in advance for any early pick-up before 3:30 pm. We will make sure a staff member is available to assist with the early pick-up.

4) Late Pick-Up Policy
A $20 flat fee will be charged for late pick-ups.
Campers will not be allowed to return the next day until the late pick-up fee is paid.
By signing the below I am acknowledging that I have read and understand the above drop-off and pick-up procedure.*

Powered by Jotform SignClear
Refund Policy:

Camp registration fees are non-refundable after May 1st, 2025. If a family needs to cancel their camper's registration, the parent or guardian who completed the registration must call and speak with a staff member to process the cancellation. Late cancellations will not be refunded as all materials have been purchased for your camper.

Please note that refunds will not be issued for individual days missed during the camp week. Timely cancellations allow us to offer the spot to a child on our waitlist, ensuring every camper has the opportunity to participate.
By signing the below I am acknowledging that I have read and understand the above refund policy. *

Powered by Jotform SignClear
Photo Release:

Any photos taken of campers are for Empowerment Farm, Inc. use only. Images may be used for grant applications, reports, collateral material and promotional use by Empowerment Farm, Inc.
By signing the below I am acknowledging that I have read and understand the above Photo Release policy.*

Powered by Jotform SignClear
Safety Policy

Camp participation is contingent on each camper’s ability to follow directions and safety procedures, as well as demonstrate respect toward fellow campers, staff, volunteers, animals, and the farm environment.

Empowerment Farm, Inc. is committed to maintaining a safe, inclusive, and positive atmosphere, free from bullying, fighting, or aggressive behavior. If a camper fails to follow safety guidelines or disrupts the experience of others, parents or guardians will be contacted to pick up their child.

For the well-being of all participants, disruptive campers will be required to leave, ensuring a safe and enjoyable experience for everyone.
By signing the below I am acknowledging that I have read and understand the above safety policy.*

Powered by Jotform SignClear
Empowerment Farm is a Not-For-Profit Farm Operating under Agritourism. Please read the below regarding state law related to agritourism operations:

Under Florida law, an agritourism operator is not liable for injury or death of, or damage or loss to, a participant in an agritourism activity conducted at this agritourism location if such injury, death, damage, or loss results from the inherent risks of the agritourism activity. Inherent risks of agritourism activities include, among others, risks of injury inherent to land, equipment, and animals, as well as the potential for you to act in a negligent manner that may contribute to your injury, death, damage, or loss. You are assuming the risk of participating in this agritourism activity.
By signing the below I am acknowledging that I have read and understand the above Florida Agritourism Law.*

Powered by Jotform SignClear
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE. I AM CONFIRMING WITH MY SIGNATURE THAT i HAVE READ AND AGREE TO ALL TERMS AND CONDITIONS ABOVE.
Date*

MonthDayYear
Date
Signature*

Powered by Jotform SignClear