Summer Camp Registration Form
Click the drop-down to fill out the required information
Camper Information
Camper Full Name
First Name
Last Name
Camper Date of Birth
-
Month
-
Day
Year
Date
Age
Gender
Male
Female
Grade Completed (as of current school year)
Camp Selection
Which Camp is the Camper Attending?
Farm Camp (June 8-11)
Farm Camp (June 15-18)
Farm Camp (June 22-25)
Horse Camp (June 8-11)
Horse Camp (June 22-25)
Horse Camp (July 6-9)
Horse Camp (July 20-23)
Camper T-Shirt
T-Shirt Size?
Youth XS
Youth S
Youth M
Youth L
Adult S
Adult M
Adult L
Adult XL
Medical Information
Does the camper have any food allergies?
Yes
No
If yes, please list all food allergies
Does the camper have any other allergies? If yes please explain.
(medications, environmental, etc.)
Does the camper have any medical conditions we should be aware of?
Is the camper currently taking any medications?
Yes
No
If yes, please list medications and instructions
Dietary Restrictions (vegetarian, gluten-free, etc.)
Physician Name
First Name
Last Name
Physician Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Health Insurance Provider
Insurance Policy Number
Parent/Guardian Information
Parent/Guardian Full Name
First Name
Last Name
Relationship to Camper
(Father, Mother, etc.)
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Information (Other than parent/guardian listed above)
Emergency Contact Name
First Name
Last Name
Relationship to Camper
(Father, Mother, etc.)
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Pick-Up
Name(s) of individuals authorized to pick up camper (Add their Phone Number(s))
Camper Experience & Notes
Special needs or accommodations
Anything else staff should know about the camper
Waivers & Permissions
Emergency Medical Treatment Authorization
*
Signature (Participant or Parent/Guardian)
*
Liability Waiver
*
Participate Name:
*
First Name
Last Name
Signature
*
Photo/Media Release Permission (Optional)
Yes
No
Participate Name:
*
First Name
Last Name
Signature
*
Signature
Signature
Date
-
Month
-
Day
Year
Date
Payment Amount ($150 Registration Fee)
prev
next
( X )
USD
Description
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
Expiration Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Year
SUBMIT
SUBMIT
Should be Empty: