Farm Camp Registration Form

Camper Information

Camper Name*

First Last

Date of Birth*

Gender*

What is your camper's T-shirt size?*

Youth Extra Small
Youth Small
Youth Medium
Youth Large
Youth Extra Large
Adult Small
Adult Medium
Adult Large
Adult Extra Large

Which week(s) are you signing up for?

6/27 - 7/1
7/5 - 7/8
7/11 - 7/15
7/18 - 7-22
7/25 - 7/29
8/1 - 8/5
8/8 - 8/12
8/15 - 8/19

How did you find out about Carnation Farms camps?

Primary Legal Guardian Information

Primary Guardian Name*

First Last

Phone Number (Primary)*

Phone Number (Alternative)*

Email (Required for camp correspondence)*

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact Information

Must be different from the primary legal guardian

Emergency Contact Name*

First Last

Relationship to Camper*

Phone Number (Primary)*

Authorized Pick-Up

Please indicate up to two drivers that may drop off or pick up the camper, even if the same as contacts above. These will be the only individuals allowed to pick up your camper. If there are any changes to this information, please submit it in writing from the primary legal guardian’s email address or via a signed note at least 24 hours in advance of the change.

Authorized Driver #1*

First Last

Phone Number (Primary)*

Authorized Driver #2*

First Last

Phone Number (Primary)*

Health Information

By fully sharing your campers medical and behavioral needs, you are allowing us to best support them. We cannot plan for special accommodations if we don’t know what is needed. Please give us all significant health information, even if it does not seem relevant. Safety of all our campers is a top priority. Carnation Farms’ staff are trained in CPR and First Aid, however there is no registered nurse on site. Carnation Farm’s staff are not authorized to administer medications to campers, however we can remind campers that it is time to take doses and we can hold those doses in a lock box when not in use. Medication must be clearly labeled with your child’s name. Campers with specific medical needs are able to attend with a caregiver at no additional cost.

Please specify any medical or health concerns, or special needs for the camper. Check all that apply.

Physical health needs
Aide required
Medications
Allergies - Environmental
Allergies - Food (please explain below)
Other

If you checked any of the boxes above, please explain below.

Please specify any behavioral or social-emotional special needs for the camper. Please include how best to support these needs. If more space is needed, please email education@carnationfarms.org

If camper has an epi-pen prescription, can your camper self-administer the epi-pen?

Yes
No

Is the camper allergic to bee stings?*

Yes
No
Don't know/Never been stung

Please list the date of the camper’s last tetanus shot*

Insurance provider*

Policy or Medicaid number*

If no insurance please check here. We will follow up with details regarding potential medical emergency procedures.

No insurance

Medical Attention Policy*

By submitting this form I authorize staff in the child care program who are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility and to secure necessary medical treatment for my child.

I acknowledge I have read the above statement

Camper Safety Policy*

In order to keep all campers safe during their time on the farm, Carnation Farms staff will outline safety procedures and rules on a daily basis. Carnation Farms has the right to send home campers who do not adhere to safety procedures and therefore risk injuring themselves or another camper. If a camper is not following safety procedure and is unable to respond to coaching from staff, parents will be contacted and asked to speak to their camper about the issue. If the camper continues to break safety rules, the camper will be sent home and no refund will be issued.

I acknowledge I have read the above statement

Carnation Farms Informed Consent and Release of Liability Documents

I certify that I am at least 18 years of age, and that I have the legal right/guardianship status to commit myself or the individual I am enrolling to the statements I am checking and to which I am applying my signature on this registration form.*

Yes
Yes

I agree to participate, or I permit the participation of the person I am enrolling, in the Carnation Farms program described on this form using outdoor and/or indoor adventure learning activities. I acknowledge that I have been advised that I, or my enrollee, can decline to participate in all of, or any part of, the activities occurring during this program if I/they wish. I/they will only engage in the activities I consider will not put my/their physical or emotional health at risk. I hereby hold harmless and release Carnation Farms, its employees and its contractors from any and all liability with relationship to my/my enrollee’s participation in the program. This release includes the transportation to and from the site of the activities, as well as the activities themselves, and covers all the sessions of a program occurring over time. This release does not, however, apply to injuries or damages caused by the gross negligence or willful misconduct by Carnation Farms, its employees, or its contractors.*

Yes
No

In order to keep all campers safe during their time on the farm, Carnation Farms staff will outline safety procedures and rules on a daily basis. Carnation Farms has the right to send home campers who do not adhere to safety procedures and therefore risk injuring themselves or another camper. If a camper is not following safety procedure and is unable to respond to coaching from staff, parents will be contacted and asked to speak to their camper about the issue. If the camper continues to break safety rules, the camper will be sent home and no refund will be issued.

I grant Carnation Farms, and persons or organizations acting for or through them, the right to use, reproduce, assign, and/or distribute photographs, films, videotapes and sound recording of myself/my enrollee, for use in educational or promotional materials they create.*

Yes
No

Payment Information

A deposit of $50 is due at the time of registration. Please choose which of the pricing options below best suits their family. An invoice for the remaining balance will be sent over once registration is confirmed.

Value-Added Price ($425) Our goal is to provide programming at a price affordable for all families. By contributing at this price, your additional payment will goes towards the scholarship fund for Farm Camp, allowing more campers to enjoy our programming.

Regular Price ($380) Includes all programing, play, and dirty hands. Price for July 5-8, will be $300.

Reduced Price ($100 - $300) Carnation Farms offers limited need-based scholarships for our Farm Camps. Please register by choosing this option below and we will contact you for more information.

Payment Selection

Choose your payment*

Value-Added ($425)
Regular Price ($380)
Reduced Price ($100 - $300)

Thank you for taking the time to complete this form.

Once your form has been reviewed we will send you an invoice for the remainder of your payment. We will send out more details like what to bring each day and directions to the farm when we are closer to your camp week. If you have any questions please reach out to education@carnationfarms.org