Pine Creek Farm Summer Camp Registration Form

Pine Creek Farm Summer Camp

5069 Fisher Rd Glen Rock, PA17327 (Enter Fisher Rd by the Rutter's on 851) alizaholcomb5@gmail.com
Child's name

First NameLast Name
Child's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
Parents E-mail
example@example.com
Parents' Phone Number
This is my:
Emergency Contact Information
Emergency Contact # 1

First NameLast Name
Phone Number
Emergency Contact # 2

First NameLast Name
Phone Number
Medical Information
Medication - yes/no (If yes, please list the medication/medications and any important details)
Allergies - yes/no (If yes, please list the allergies and any other important details)
Doctor's Name

First NameLast Name
Doctor's Phone Number
Is your child up to date on their tetanus immunization?

YESNO
Please select which camp your child will be attending

June 23 - 27 (4-7yrs) $450 9am-3pmJuly 14 - 18 (8-10yrs) $450 9am-3pmJuly 21 - 25 (4-7yrs) $450 9am-3pmAug 4 - 8 (8-10yrs) $450 9am-3pm
5 children are required to sign up for the camp in order for it to run. If the camp does not fill, the deposit will be refunded. There is a maximum amount of 20 children per camp so spots are limited.
If you need before and after care, please email us directly at alizaholcomb5@gmail.com and we will do our best to accommodate your needs!

***Before and after care cost an extra $25 for every hour outside of the designated camp hours***
* In order to hold your child's spot, the $50 deposit must be given and this form must be filled out completely
*The full payment minus the deposit, is due on or before the first day of camp. If the payment is not received on or before the first day of camp, your child will not be able to attend camp until payment is received.
How to pay

For the deposit, mail a check to 4145 Johnson Rd Glen Rock, PA 17327. Checks should be made out to Pine Creek Farm LLC. Full camp payment can be mailed to the same address or you can pay with cash on the first day of camp.
Summer Camp Waiver and Rules Agreement:

I (parent/gaurdian) understand that no refund will be given unless the camp does not fill. In the circumstance where the camp does not fill, the $50 deposit will be refunded. If the camp does fill and my child fails to attend, my $50 deposit will not be refunded unless written notice has been given 30 days prior to the camp's start date, that states your child is no longer able to attend the camp.

I (parent/gaurdian) understand that my child can be terminated from the camp if he/she does not follow the rules and relgulations made by the owner, counselors, empolyess and helpers at Pine Creek Farm. I understand that I will not be given a refund if my child is terminated for not obeying the rule and relgulations.

I (parent/gaurdian) understand that the full payment minus the deposit is due on or before the first day of camp. If the payment is not received prior to starting the first day of camp, my child will not be able to attend the camp until the payment is given.

I (parent/gaurdian) give Pine Creek Farm, LLC and their owners, counselors, empolyees, and helpers the permission to act on behalf of my child and myself in any medical emergency that requries medical attention. I agree to hold Pine Creek Farm, LLC and their owners, counselors, empolyees, and helpers completley harmless and not liable in any claim of action, injury or damage while on the Pine Creek Farm Property.

I(parent/gaurdian) have stated my child's medical conditions, and will provide an update for any changes in my child's health status prior to the camp.

My child has no impairments that restrict him/her from participating in the camp and its actvities.

I (parent/gaurdian) understand that my failure to do so may pose a threat to my child's health and/physical well being and I hold harmless Pine Creeek Farm LLC and the owners, employees, and volunteers from any liability whatsoever arising from failure to disclose on my part.

Warning: You assume the risk of equine activites pursuant to Pennsylvania Law.

By my electronic signature below, I agree to the Summer Camp Waiver and Rules Agreement above.
Date

MonthDayYear
Date
Parent / Guardian Signature

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Pine Creek Farm Summer Camp

Emergency Contact Information

Medical Information

5 children are required to sign up for the camp in order for it to run. If the camp does not fill, the deposit will be refunded. There is a maximum amount of 20 children per camp so spots are limited.

If you need before and after care, please email us directly at alizaholcomb5@gmail.com and we will do our best to accommodate your needs!

* In order to hold your child's spot, the $50 deposit must be given and this form must be filled out completely

*The full payment minus the deposit, is due on or before the first day of camp. If the payment is not received on or before the first day of camp, your child will not be able to attend camp until payment is received.

How to pay