(For Application- Print, HIGHLIGHT entire form and hit (Cntl+ print) 5pages

2017 Camp Application for BENTON FAMILY FARM

ADVENTURE DAYS ON THE FARM 2017

New campers $195 per week

11896 Old Lexington Pike Walton KY. 41094

Please E-mail us prior to mailing application to confirm the session you want is open and not booked. After you get confirmation back from us mail form and deposit  to the address above...

Please check the session or sessions your child will be attending,

Session 1- June19-23 __________           Session 2- June26-30_________    Session 3-July 10-14________    Session-4 July 17-21_____    (Children can sign up for more than1 session as each week is always unique with different children and varied activities)   Always an Adventure!           

Child's name____________________________ any other children attending camp Y/N___

Age:_____ DOB:____________ Gender:_______PAST CAMPER. Yes____ No______   Past Junior counselor______

Child’s address:_________________________________________________________________________________________________

City:_________________ State:_______ Zip:______________ County:_________________

Main contact number:___________________________

Emergency contact number:______________________  

Email:_________________________________________

Mothers Name:______________________________________________

Mother contact#___________________

 

Father Name:________________________________________________

Father contact#____________________

 

Alternate Emergency Contacts:

1-Name:______________________________________________Relationship

Number:____________________

2-Name:_______________________________________________Relationship

Number:____________________

IN CASE OF AN EMERGENCY WE WILL CONTACT THE NUMBERS ABOVE

Child’s School:________________________________     Last Grade Completed:______

Child resides with: _____ Mother     _____ Father     _____ Both

-Camp Fees: Total for the week is $195.00 deposit due at the time of the application is $75.00 (this is non refundable)

-IF YOU WISH TO PAY THE FULL TOTAL NOW PLEASE DO SO, IF NOT THE REMAINDER IS DUE THE FIRST DAY OF CAMP.

-BE SURE YOUR DEPOSIT OF $75.00 IS ATTACHED WITH THIS APPLICATION. 

-MAKE CHECKS PAYABLE TO- Benton Family Farm    Note session and child's name in notes on check

CHECK NUMBER:__________AMOUNT OF CHECK:_______

PLEASE CHECK: DEPOSIT_________FULL AMOUNT_________

Please Read.....

-Returning campers price: $185.00         Same deposit is required.       Junior Counselors $185 (Must have attended our camp and approved by Farmer Mary)

-Any Campers with one sibling attending must put on second application on top of application $20 off per my second child enrolled.

-If you have more than two attending in your family please email Farmer Mary for an adjusted rate. bentonfamilyfarm@aol.com

 

-Returning campers who get a NEW camper to sign up receive $10 off ! This is good for up to 2 referrals. Be sure to note on top of your application $10 off NEW Camper Referral with new campers name and week attending. ($20 is most one camper can discount)

 Child’s information:

Does your child have allergies Yes_____ No___ If so please list:_____________________________________________________________________

_____________________________________________________________________________________________________________________________________________

Does your Child have any restrictions such as asthma, special needs, or medical conditions? Please list:_____________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Child’s Family Doctor:_______________________________________

Dr.Address/City/State/Zip:____________________________________________________________________________________________________________________________________________________

Doctor’s Phone Number:___________________________

Any other information on your child that we may need to know:_________________________________Medication during camp?___________________________

____________________________________________________________________________________HOBBIES:  Please list as we use this to group our teams!________________________________________________________________________________________________________________________________________________________________________.

BENTON FAMILY FARM RESERVES THE RIGHT TO REFUSE REGISTRATION FOR HEATH REASONs, AS THE THE FARM ENVIRONMENT. 

FARM CAMP MAY NOT BE SUITABLE FOR CHILDREN WITH SEVERE HAY, BEE, WHEAT, AND/OR FOOD ALLERGIES. No allergies per child's past history? yes_____   no____

 

-We will contact you with a confirmation letter, informational packet, and instructions for farm camp.

I the Parent/Guardian of_____________________________ give permission for my child to receive emergency medical care if so needed. 

Parent Sign:________________________________                     Date:_______________

I also understand that photos of Farm Camp may be taken during the week and may be used on the website/facebook in farm advertising and our publications. Is this ok yes_____ no______

Parent Sign:_____________________________________

Date:_______________

Does Child have medical insurance? Yes___   No___Name(Company)______________________

#_____________________________________________

Signature of parent/guardian:______________________________________________

Date:_____________________

Signature of parent/guardian:___________________________________

Date:_____________________

T-shirt Size- please circle           CHILD SIZE-       Small     Medium     Large     x-largeYOUTH SIZES

                                                          ADULT SIZE-    - Small     Medium     Large     x-large

Parents and others may come for the Camp Show and Presentation at 2:00 pm on Friday. You can arrive at 1:45 pm we will promptly start at 2pm. Bring a lawn chair if you are able otherwise we have benches.