Broadturn Farm
Camp Sign-up Form Summer 2008
Child's
Name:__________________________________Birthdate:____________________Age: ___
Parent's
names______________________________________________________________________
Address:___________________________________________________________________________
City, State, Zip
Code:______________________________________ Email____________________
Home phone:_________________________________ Cell Phone
____________________________
In an emergency. Please use the following contacts in the
order in which they appear:
1. Name
_________________________cell____________________home ____________________
2. Name
_________________________cell____________________home ____________________
3. Name _________________________cell____________________home
____________________
Please check the camp week your child will be attending:
|
Week # |
Date |
Half day (4-5 year old)
$100 |
Full day (6-10 year
old)$185 |
Amount |
|
1 |
June
23-June 27 |
|
|
|
|
2 |
June 30-July 3 (no camp July 4th)
discounted rate ($80 ½ day; $148 full day) |
|
|
|
|
3 |
July
7-July 11 |
|
|
|
|
4 |
July
14- July 18 |
|
|
|
|
5 |
July
21- July 25 |
|
|
|
|
6 |
July
28- August 1 |
|
|
|
|
7 |
August
4- August 8 |
|
|
|
|
8 |
August
11-August 15 |
|
|
|
|
9 |
August
18-August 22 (For
campers age 11-14 only) $210 |
No Programming for 4-5
year olds |
No Programming for 6-10
year olds |
|
Make checks payable to
Broadturn Farm and send to Broadturn Farm, 388 Broadturn Rd, Scarborough, ME
04074
If we are notified of a
cancellation prior to May 25 th, we will issue a refund, less $25 processing
fee.
Total
$ __________
Any required medications and dosage instructions___________________________________________
Medication side effects_____________________________Allergies/treatments___________________
Date of last tetnus shot _____________Please explain any other health issues or concerns___________
___________________________________________________________________________________
I state that the health
history above is correct. My child, ___________________, has permission to
participate in all farm camp activities. I understand these activities may
include certain risks. I authorize Broadturn Farm Camp (1) to give
medications as listed to my child (2) to secure emergency medical care
at my expense if I am unable to be reached in the event of an emergency; (3)
to use my child's photo in promotional materials. I specifically release
Broadturn Farm Camp, its owners, directors, employees, and volunteers from any
claim of any kind arising from my child's participation in the Broadturn Farm
Camp program.
(parent/guardian signature) (date)