(For Application- Print, HIGHLIGHT entire form and hit (Cntl+ print) 5pages
2017 Camp Application for BENTON FAMILY FARM
ADVENTURE DAYS ON THE FARM 2017
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______
City:_________________ State:_______ Zip:______________ County:_________________
Main contact number:___________________________
Emergency contact number:______________________
Alternate Emergency Contacts:
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_________
-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. firstname.lastname@example.org
-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)
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:_______________________________________
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______
Does Child have medical insurance? Yes___ No___Name(Company)______________________
Signature of parent/guardian:______________________________________________
Signature of parent/guardian:___________________________________
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.