Farm Camp 2017

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Farm Camp 2017

Thank you for your interest in our Farm Camp program. Unfortunately, Farm Camp has filled faster than ever this year and is FULL at this time. If you are interested in being put on our wait list or attending next year, please contact us or fill out this form. Thank you!

Make it a DAIRY good day!
Jacki - rodenbarnyard@gmail.com or 262-689-7521

Email *

Registration Form

Please fill out ONE registration form per child. If you would like a hard-copy registration please send us an email and mail in the completed form.

Participant First Name *

Participant Last Name *

Gender *

Female

Male

Date of Birth *

YYYY

Address *

City *

State *

Zip Code *

Week Attending *

All of our camps are full at this time. If you'd like to be added to a waiting list please note which camp in the "other" section below.

Other:

Required

Shirt Size *

Youth X-Small

Youth Small

Youth Medium

Youth Large

Youth X-Large

Adult Small

Adult Medium

Adult Large

Other:

Parent/Guardian First Name(s) *

Parent/Guardian Last Name(s): *

Daytime Phone Number *

Cell Phone Number

Email *

Group Placement Requests (with or without siblings/other participants)

If paying for more than one participant, please list all their names here:

Liability Release & Medical Form

Please fill out one Liability Release & Medical Form per camper. If you would like a hard-copy of this form please send us an email.

Please check each paragraph stating that you (parent/guardian) have read and understand. *

In consideration for my child being accepted by Roden Barnyard Adventures, LLC to participate in the below described program, we(I) [and on behalf of our (my) child participant] do hereby release, forever discharge and agree to hold harmless Roden Barnyard Adventures, LLC and the staff thereof from any and all liability, claims or demands for personal injury, sickness, or death, as well as property damage and expenses, of any nature whatsoever, which may be incurred by the undersigned and the child-participant that occur while said child is participating in the Farm Adventure Week program.

Furthermore, we (I) [and on behalf of our (my) child-participant] hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation. I authorize the staff of Roden Barnyard Adventures, LLC to act for me according to their best judgment in any emergency requiring medical attention. I understand that I will be financially responsible for all charges and fees incurred in the rendering of said emergency treatment, regardless of whether or not my medical insurance would cover such charges and fees. I further understand that I am required to maintain and carry accident insurance coverage for the child listed on this application, and verify that the coverage information that I have provided is accurate and true. I have no knowledge of any physical impairment that would be affected by the named child participating in the Farm Adventure Week program as outlined in the brochure.

I also understand that Roden Barnyard Adventures, LLC retains the right to use for publicity and advertising purposes, photographs and video of youth taken during the week. Further, authorization and permission is hereby given to the program to provide any necessary transportation and food for this participant.

We (I) are the parent(s) of legal guardian(s) of this participant, and hereby grant our (my) permission for him/her to participate fully in the program.

Required

Your child may be picked up by (include your name) *

Your child may NOT be picked up by

Insurance Information/Insurer

Please provide proof of insurance by mailing a copy or fill out the information here.

Policy Holder

Amount of Coverage

Dietary Restrictions/Special Considerations/Medical Concerns:

Has anaphylaxis (severe allergic reaction) ever occurred to your child? *

Yes

If allergic reaction occurs, can we administer an oral antihistamine (e.g. Benadryll) if necessary? *

Yes

#1 Emergency Contact *

Relationship (#1 Emergency Contact) *

Phone Number (#1 Emergency Contact) *

#2 Emergency Contact *

Relationship (#2 Emergency Contact) *

Phone Number (#2 Emergency Contact) *

Code of Conduct *

Please check each paragraph stating you (the participant) have read and understand.

Obey instructions the first time they are given by all counselors.

This is a learning experience, as well as a fun adventure. Accept others in the group and the program content.

Be considerate and courteous of other youth and adults, animals and their property.

Use good judgement and do what you know is right for the situation.

It is your responsibility to be on time and to participate in the programs.

Wear appropriate dress for the various activities.

Required

How did you hear about camp?

Check ALL that apply.

Family/Friend

Organizaiton

Flyer Around Town

School

Farm Tour

Other:

Electronic Signature (Parent) *

If behavior problems are not resolved, parents will be called and the youth will have to return at his/her own expense.

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