Camp Registration Form 2022

Child’s Name	Age	DOB
Address	Zip
Parent Name	Parent Phone
Parent Email
Farm Camp Options	July 11th-15th $225 per child	July 25th-29th $225 per child
Check one or both
Emergency Contact Information
Name	Cell
Relationship	Work Phone
Name	Cell
Relationship	Work Phone
Special instructions or other information about your child that would be helpful for us to know. (i.e., food or insect allergies, or medical conditions.)
Yes Does your child require an Epi-pen?	No
If yes, you must provide Roots with an Epi-pen to be kept at camp during your child’s enrollment. Epi-pen must be accompanied with a current prescription and a doctor’s note.

Parent Consent Form
Roots Farm EDU does not discriminate on the basis of race, color, sex, handicap, religion or national origin. Roots reserves the right at its sole discretion to refuse an application or dismiss a child from camp. No refund will be made of fees if the child has attended any portion of the camping period
Parent/Guardian's Printed Name & Signature (sign at drop off)
I understand and accept these guidelines
I give Roots Farm EDU permission to photograph and/or videotape my child for public relations and/or marketing purposes. Photos will remain archived at Roots Farm EDU and can be used for promotional purposes without notification.
Parent/Guardian's Printed Name & Signature (sign at drop off)
I give permission for Roots Farm EDU to transport my child off camp property for the purpose of field trips and/or medical care.
Parent/Guardian's Printed Name & Signature (sign at drop off)
I authorize the camp management to act as the agent of the parents in any emergency situation or to administer basic first aid for the health and welfare of the camper involved. I am responsible for the expenses involved if the services of a physician or hospital are required. Please request a waiver for persons requesting exemption from medical treatment.
Parent/Guardian's Printed Name & Signature (sign at drop off)
Hospital preferred
By signing below I agree to adhere to all the Policies and Procedures set for by Roots Farm EDU.
Parent/Guardian's Printed Name & Signature (sign at drop off)
Date

Download a copy and email to Rootsfarmedu@protonmail.com

Payment can be mailed to Roots Farm EDU 22069 Palo Way, Palo Cedro, Ca. 96073

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For office use only

Date:____________________________________

Paid by check(#) or cash ______________________

Recipient name ______________________