2019 Auerfarm Adventures
Welcome to Summer 2019 at the 4-H Education Center at Auerfarm! Please use the form below to register your child for our Summer Programs. Only one child per form please. To mail in your registration, please contact Mark DiBella at 860.242.7144 or mdibella@auerfarm.org to have the registration form emailed to you.
Email address *
Child's First Name: *
Your answer
Child's Last Name:
Your answer
Date of Birth: *
mm/dd/yr
Your answer
Gender: *
Address: *
Your answer
Town: *
Your answer
State: *
Zip Code: *
Your answer
T-Shirt Size:
Session(s) signing up for: Adventures at Auerfarm (3-5 yrs). All sessions run from 8:30am - 12:30pm. *
Required
Parent/Guardian Name (First and Last): *
Your answer
E-mail: *
Your answer
Address: *
Your answer
Town: *
Your answer
State: *
Your answer
Zip Code: *
Your answer
Home Phone: *
Your answer
Cell Phone: *
Your answer
Work Phone:
Your answer
Emergency Contact Name: *
Your answer
Relationship to Child: *
Your answer
Home Phone: *
Your answer
Cell Phone: *
Your answer
Work Phone:
Your answer
Please let us know if your child has any dietary restrictions, allergies or special needs we should be aware of: *
Your answer
Please list names of people who are eligible to pick up your child--Photo ID will be required: *
Your answer
How did you learn about our programs?
Your answer
Photo Release: I grant Auerfarm permission to use my child's photo in any marketing/website/social media posts.
Payment Information
Full payment should be mailed to 4-H Education Center at Auerfarm, 158 Auer Farm Road, Bloomfield, CT 06002. To pay by credit card, please contact Mark DiBella at 860.242.7144.

Adventures & Environmentalists: $200 per week

Cancellation policy: 100% refund if notified 4 weeks prior to program, 75% three week prior, 50% two weeks prior, and no refund with less than two weeks notice.

A copy of your responses will be emailed to the address you provided.
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