Registration Form
Name of student :
Your answer
Name of camp/workshop:
Your answer
Birth date (if minor) :
Your answer
Home address :
Your answer
Mother’s name (if minor):
Your answer
Work phone :
Your answer
Cell phone :
Your answer
Email :
Your answer
Father’s name (if minor) :
Your answer
Home phone :
Your answer
Work phone :
Your answer
Cell phone :
Your answer
Email :
Your answer
Are there any conditions that we should be aware of that may affect the student’s ability to participate in our programs?
Your answer
INFO
Refund and Cancellation: For cancellations prior to June 15, a full refund minus $100 non-refundable deposit will be issued. For cancellation after June 15, the total fee is forfeited. In the event that your child enrolls in camp and withdraws because of homesickness or is asked to leave because of misconduct, there will be no refund.

Student Dismissal: A student whose behavior is disruptive to the program or harmful to himself/herself, others, or the property of camp or others, will be dismissed at the discretion of the Directors, with no refund of fee.
Submit a Photo: Please submit a current photo of student (within the last year). It can be a simple snapshot or school photo. This will be kept in student’s personal file.

We, the undersigned parents (or guardians) of the student named on this application, acknowledge that we are fully aware that certain elements of danger are inherent in the activities sponsored by Heartmoor Farm, Inc., which are beyond the control of the agents, the land owners, and employees of Heartmoor Farm, Inc., and that participation in any program activities may entail unavoidable risk of personal injury, death, and loss of or damage to property. We are aware of the types of activities in which the child will be participating during his/her stay and have been given ample opportunity to ask any questions which we may have about the environment in which the child will live and the activities in which he or she will participate. We are aware of the dangers that are inherent in the operation of any child’s camp and in the child’s participation in all camp activities on or off premises of said camp including, but not limited to, hiking, athletics, including bodily contact, use of tools and equipment, backpacking, outdoor-living skills, and vehicular travel.
We grant permission to use any photographs or video for promotional use, knowing it will be done in good taste. We have read and understand the terms and conditions of this Agreement/Waiver and we agree to subscribe to them.

Type Name Here Certifying You Agree With The Above:
Your answer
Date
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To Complete Your Registration: (1) Click the Blue SUBMIT button below and your form will be sent to us. (2) Choose the appropriate Paypal link below to pay for your class.
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