Family Farm Camp Registration

Name_________________________ Age_________ Sex M / F Birthday_____/_____/____

Address_________________________________ City ___________________ State _____ Zip ___________

Phone # Resident_________________Phone # if parents cannot be reached at home or work ______________

Father's Name_______________ Father's Work Place ____________ Father's Phone____________

Mother's Name_______________ Mother's Work Place___________ Mother's Phone____________

Physician's Name________________ Work Place______________ Physician's Phone____________

Additional Information: _______________________________________________________________

__________________________________________________________________________________

Father's Email__________________________ Mother's Email___________________________________

DAY CAMP CONSENT FOR EMERGENCY MEDICAL CARE. TRANSPORTATION. FIELD TRIPS, AND CAMP ACTIVITIES. I hereby request and give consent to the directors of Family Farm or duly appointed representative, for my child to receive such medical or surgical aid as may be deemed necessary and expedient by a duly licensed or recognized physician or surgeon in case of an emergency, when the parents cannot be reached. I also give my consent for Family Farm to take my child on designated field trips or to transport in emergencies. My child has permission to participate in activities such as horseback riding, archery, riflery, fishing, canoeing, riding cable swings, games, creek activities and other activities that the camp directors feel are safe and supervised. I give Family Farm Camp permission to use photos taken of my child at camp for camp publications.

Parent or Guardian signature (must be signed) ____________________________________

FEES: Camp Fee - $100.00 (1 child) *$180.00 (2 children) *$270.00 (3 children) (must be siblings)

Deposit $20.00 * Deposit is part of total registration * Transportation Fee -$10.00 per week/per child. Please include transportation fee with registration.

2009 Camp Dates. Please Check One

Camp 1 June 8-11_______ Camp 2 June 15-18 _______Camp 3 June 22-25_______

Camp 4 June 29-July 2_______Camp 5 July 6-9 _______ Camp 6 July 13-16_______

Camp 7 July 20- July 23_______ Camp 8 July 27-30_______

Transportation needed from:

Benton ________ Hot Springs ________ Arkadelphia________

FEES ENCLOSED: Camp Fee__________ Transportation Fee_______ Deposit________

(Deposit is part of Total Registration.) TOTAL ENCLOSED______________

MAIL TO: FAMILY FARM * 18448 Hwy 67 * Malvern, AR 72104