Farm Camp 2017
Thank you for your interest in our Farm Camp program. Unfortunately, Farm Camp has filled faster than ever this year and is FULL at this time. If you are interested in being put on our wait list or attending next year, please contact us or fill out this form. Thank you!

Make it a DAIRY good day!
Jacki - rodenbarnyard@gmail.com or 262-689-7521

Email address
Registration Form
Please fill out ONE registration form per child. If you would like a hard-copy registration please send us an email and mail in the completed form.
Participant First Name
Your answer
Participant Last Name
Your answer
Gender
Date of Birth
MM
/
DD
/
YYYY
Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Week Attending
All of our camps are full at this time. If you'd like to be added to a waiting list please note which camp in the "other" section below.
Required
Shirt Size
Parent/Guardian First Name(s)
Your answer
Parent/Guardian Last Name(s):
Your answer
Daytime Phone Number
Your answer
Cell Phone Number
Your answer
Email
Your answer
Group Placement Requests (with or without siblings/other participants)
Your answer
If paying for more than one participant, please list all their names here:
Your answer
Liability Release & Medical Form
Please fill out one Liability Release & Medical Form per camper. If you would like a hard-copy of this form please send us an email.
Please check each paragraph stating that you (parent/guardian) have read and understand.
Required
Your child may be picked up by (include your name)
Your answer
Your child may NOT be picked up by
Your answer
Insurance Information/Insurer
Please provide proof of insurance by mailing a copy or fill out the information here.
Your answer
Policy Holder
Your answer
Amount of Coverage
Your answer
Dietary Restrictions/Special Considerations/Medical Concerns:
Your answer
Has anaphylaxis (severe allergic reaction) ever occurred to your child?
If allergic reaction occurs, can we administer an oral antihistamine (e.g. Benadryll) if necessary?
#1 Emergency Contact
Your answer
Relationship (#1 Emergency Contact)
Your answer
Phone Number (#1 Emergency Contact)
Your answer
#2 Emergency Contact
Your answer
Relationship (#2 Emergency Contact)
Your answer
Phone Number (#2 Emergency Contact)
Your answer
Code of Conduct
Please check each paragraph stating you (the participant) have read and understand.
Required
How did you hear about camp?
Check ALL that apply.
Electronic Signature (Parent)
If behavior problems are not resolved, parents will be called and the youth will have to return at his/her own expense.
Your answer
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