2019 Farm Camp Registration
Email address *
2019 Farm Camp Registration
Please fill out a new form for each child attending farm camp. Please note registration is NOT complete until payment is received.
From the list below, please check all the camps that your child will attend: *
Campers will be put into groups according to age: 3-4, 5-6, 7-8, and 9-12
Required
Would you like to enroll your child in Half Day (option available for 3-6 year olds only) or Full Day (all ages)? *
Would you like to add on Before and/or After Care? *
Required
Child's Name *
Your answer
Child's age at start of camp *
Your answer
Birth Date *
MM
/
DD
/
YYYY
Address *
Your answer
Parent or Guardian's Name 1 *
Your answer
Parent or Guardian's Cell Phone Number 1 *
Your answer
Parent or Guardian's Email 1 *
Your answer
Parent or Guardian's Name 2
Your answer
Parent or Guardian's Cell Phone Number 2
Your answer
Parent or Guardian's Email 2
Your answer
Parent or Guardian's Home Phone Numbers
Your answer
Parent or Guardian's Work Phone Numbers
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number
Your answer
Does your child have any physical, developmental, or learning challenges that might make some activities difficult? If so, please explain: *
Your answer
Does your child have any allergies (food, environmental, medicines)? If so, please list them and include allergic symptoms for each: *
Your answer
Does your child need to have medication administered or available while at camp? If so, we will send you a camp medication authorization form. *
What is your child's T-shirt size? Please note that the T-shirts we order run small. If in doubt size up! We will be providing your child with the shirt size requested. *
Required
We love to take pictures at Common Ground Farm! Each week we will share the photos taken in an album accessible to parents, and we will share photos on our website and to promote Common Ground Farm's food access mission and programs. *
How did you hear about this program? *
Your answer
Is there anything else that you would like us to know about your child?
Your answer
Choose your payment option *
Please note that payment is not received through this form. This question serves only to verify your method of payment. **Registration is NOT complete until payment is received OR scholarship granted. Go to: STOREFRONT LINK to pay online or write a check to: Common Ground Farm, PO Box 148, Beacon, NY 12508. Families who apply for scholarships, please choose the appropriate option.
Required
WAIVER, RELEASE AND VOLUNTARY ASSUMPTION OF RISK
1. My child(ren)/ward(s) desire(s) to participate voluntarily in camp activities and educational programming sponsored by Common Ground Farm, Inc. (“Common Ground”) and held at Common Ground Farm, located on the grounds of Stony Kill Farm Environmental Education Center in the Town of Wappingers Falls.

2. I am aware that camp activities include, but are not limited to, animal encounters, gardening and agricultural activities, hiking, homesteading and culinary activities, pond and other water activities, arts and crafts, and sports and games. I am also aware that participating in these activities carries potential risks.

Understanding that camp activities carry certain inherent risks, for the sole consideration of Common Ground arranging for and providing educational camp programming, I hereby release and indefinitely discharge Common Ground, Stony Kill Foundation, Inc., and their respective officers, representatives, agents, and employees from any and all claims, demands, rights and causes of action that I may have, either on my own behalf or in my capacity as a legal representative of my child(ren)/ward(s), arising from or in any way connected with my child(ren)/ward(s)’s participation. I further covenant and agree that I will not sue the Released Parties for damages or other claims arising from my child(ren)/ward(s)’s participation in the program.

3. I understand that should a health problem arise, I will be notified promptly. If I cannot be reached by telephone, any medical treatment deemed necessary by competent medical personnel may be rendered. Necessary information may be released for emergency care and insurance purposes.

4. I HAVE READ AND UNDERSTAND THIS ENTIRE WAIVER AND AGREE TO ITS TERMS, UNDERSTAND ITS MEANING AND SIGNIFICANCE, AFFIRM THAT IHAVE NOT RELIED UPON ANY STATEMENT OR REPRESENTATION NOT
INCLUDED IN THIS WAIVER, AND VOLUNTARILY ASSUME THE RISK OF, AND CONSENT TO THE PARTICIPATION OF MY CHILD(REN)/WARD(S) IN, CAMP ACTIVITIES AT COMMON GROUND FARM. I agree my signature is legally bound by
this Waiver’s terms and conditions, and agree that no certification authority or other third-party verification is necessary to validate my signature.

5. AFFIRMATION OF PARENTAL/LEGAL GUARDIAN STATUS
I confirm that I am the parent/legal guardian of the named child(ren)/ward(s) listed
below. To agree to all aforementioned terms, print full parent/guardian name(s) to serve as an electronic signature.

*
Your answer
Full refund (minus $50 application fee per camp slot) may be granted if requested by 6/14/19; After this date, no refunds will be granted.
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