Registration Form
For Teen Camp 2019
Student's Last Name *
Your answer
Student's First Name *
Your answer
Grade student will be entering for the 2018-2019 school year *
Parent Name *
Your answer
Second Parent Name
Your answer
Cell Phone #1 *
Your answer
Cell Phone #2
Your answer
Home Phone
Your answer
Home Address
Your answer
Email Address *
Your answer
Specific Needs
The Dairy Barn welcomes students of all abilities. If your child has specific needs we should be aware of, please tell us below. Feel free to contact the Education Director to discuss any questions or concerns you may have. (Email lyn@dairybarn.org)
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone *
Your answer
Release and Permission *
By clicking the accept box, I state that In case of accident or serious illness, I request that I/we be contacted. I give permission for emergency medical treatment and to be transferred to the nearest medical facility. I agree to assume all costs related to such treatment and I release the Dairy Barn from any responsibility for injury or illness that may occur while my child participates. I also give permission for my child to participate in The Dairy Barn Teen Camp.
Transportation
Some students may drive themselves, or car pool with one another. If so, they need to be on time and understand that we will call parents if they have not arrived by 10:15am unless we are otherwise notified. Students may sign themselves in and out with permission. Please let us know how your student will arrive and depart the Dairy Barn.
Photo Release *
The Dairy Barn respects your parental rights! We love Camp publicity, but we understand not all parents are comfortable having their children’s photos published. Photographs may be taken by Dairy Barn staff and used on the Dairy Barn website, Facebook page, or in teachers personal portfolios or personal social media pages, or photos may also be taken by local news media and used in newspapers and on their websites.
Payment Options *
Select the method of payment
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The following Questions are for Administrative Purposes Only. Please leave the rest of this form blank, just scroll to bottom and click submit.
Payment Date (Admin only)
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Payment Information (Admin only)
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Payment Amount (Admin only)
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Notes (Admin only)
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