2019 Farm Camp Registration
This form begins the process of registering for a Farm Discovery Summer Camp. Your registration is complete when we receive a signed Release Form and full payment or deposit of $175 per camp and per camper registered.

Please fill out one form for each camper you are registering.

The Art on the Farm and Farm to Table Camps are for children 6-12 years old.
Sprouts Camp is for children 3-6 years old with or without a parent.
Teen Camp is for 11-16 year olds.
(please contact us if you would like to make accommodations for a sibling outside of this age range.)

REFUND POLICY:
Any payment is fully refundable up to 6 weeks before the first day of camp.
We will refund all but $100 up to 4 weeks before the first day of camp.
There will be no refund within 4 weeks of the first day of camp.

Email address *
Camper Information
Required
Camper's First Name *
Your answer
Camper's Last Name *
Your answer
Camper's Street Address *
Your answer
Camper's City *
Your answer
Camper's State *
Your answer
Camper's ZIP Code *
Your answer
Camper's Date of Birth *
mm/dd/yyyy
Your answer
Primary Parent or Guardian Information
Required
Primary Parent or Gaurdian's First Name *
Your answer
Primary Parent or Gaurdian's Last Name *
Your answer
Primary Parent or Guardian's Street Address *
Your answer
Primary Parent or Guardian's City *
Your answer
Primary Parent or Guardian's State *
Your answer
Primary Parent or Guardian's ZIP Code *
Your answer
Primary Parent or Guardian's Phone Number *
Your answer
Primary Parent or Guardian's E-mail Address *
Your answer
Second Parent or Gaurdian Information
This section is appreciated, but not required unless the camper lives and will be picked up or dropped off by a second household.
Second Parent or Gaurdian's First Name
Your answer
Second Parent or Gaurdian's Last Name
Your answer
Second Parent or Guardian's Street Address
Your answer
Second Parent or Guardian's City
Your answer
Second Parent or Guardian's State
Your answer
Second Parent or Guardian's ZIP Code
Your answer
Second Parent or Guardian's Phone Number
Your answer
Second Parent or Guardian's E-mail Address
Your answer
What session(s) are you enrolling for? *
You may choose as many as your camper is eligible for in their age range
Required
Have you participated in Farm Discovery programs before?
CONSENT FOR VIDEOTAPING OR PHOTOGRAPHY *
Farm Discovery at Live Earth uses photographers from time to time to videotape or photograph participants in events, field trips and camps. These videotapes or photographs may be used in newspapers, community newsletters, promotional literature, advertising, television, audiovisual presentations, electronic publications, or similar ways. Your child may or may not be included in some or all of the videotape or photography sessions. We may use a photograph of your child unless you do not give consent.
Required
How did you find out about camp at Live Earth Farm?
We appreciate your answer. This will help us with future outreach.
Your answer
Are you interested in financial aid for camp?
Emergency Contact Information
Required. This section is for a contact other than the parents already listed, in case we can not get in touch with a parent during an emergency.
#1 Full Name *
Your answer
#1 Phone Number(s) *
Your answer
#1 Relationship to Camper *
Your answer
#2 Full Name *
Your answer
#2 Phone Number(s) *
Your answer
#2 Relationship to Camper *
Your answer
Medical Information
Required
Camper's Physician's Name *
Your answer
Camper's Physician's Phone Number *
Your answer
Camper's Physician's Address *
Your answer
Medical Conditions *
Please check all that apply
Required
Allergies/Additional Health Notes/Dietary Restrictions
Please be specific. If your child has severe or life threatening allergies, please list them, their symptoms and warning signs, and what your course of action is when reaction begins.
Your answer
Will your child be bringing any medication with him/her to the farm?
Does s/he know how to administer it his/herself? Please list all dose/medication information.
Your answer
Optional Demographic Information
This section is optional, is kept confidential and is only collected in order for Farm Discovery to qualify for certain funding opportunities.
Ethnicity
Place of birth
Please list city, state, country
Your answer
Annual Household Income
There are farmworkers in our family
A copy of your responses will be emailed to the address you provided.
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