Summer Camp Detailed Registration Form

Conservation Camp Registration

Youth and Family Gardening Program with Conservation Education at the Dyersville Community Garden - Summer 2025. Registration is $48 per family. Payment information will be provided once our registration has ended. Scholarships are available.

Student and Family Information

We ask that students and their guardian(s) commit to attending all sessions of Conservation Camp, aside from unplanned sicknesses or emergencies, as we have a limited amount of supplies for each participant which have been graciously sponsored by local businesses along with the time donated by community volunteers. We will close registration once we have 25 families signed up.
Number of Children in Family Attending*
St. Francis Xavier ElementaryDyersville Elementary School Western DubuqueHome Schooled

Student Name

First NameLast Name
Age
Student Name

First NameLast Name
Age
Student Name

First NameLast Name
Age
Student Name

First NameLast Name
Age

Parent/Guardian Information
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.

YesNo
Please list any dates where students will not be able to attend (this is so we can provide appropriate supplies for each class)
Are there any special accommodations needed for any participants in your family?
Additional comments or questions here:
The cost of this program, per family, is $48

Payment information will be sent to participants once our registration is closed and our capacity limit is reached. If we fill our capacity, we will start a waitlist and look at reaching out to waitlist families when openings for specific classes become available throughout the summer. You will be notified of acceptance once registration is closed. We have a total capacity for 25 families this summer.
Yes, my family is interested in a scholarship
Please upload a brief essay letting us know why you are interested in participating, what you hope to learn, and if you will be able to commit to all sessions throughout the summer as well as the fall clean up.

Cancelof
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by BFF and JKPL during the selected camp. In exchange for the acceptance of said child’s candidacy, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless of BFF and JKPL 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 BFF or JKPL including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the BFF and JKPl and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
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.
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Conservation Camp Registration

Student and Family Information

The cost of this program, per family, is $48