______________________________________ _____________________________
CHILD’S FULL NAME LAST FIRST
______________________ _____ _____ ________________
BIRTHDATE (MM/DD/YY) AGE M / F GRADE IN FALL
______________________________________________________________________
CHILD'S GUARDIAN FULL NAME
__________________________ ______________________________ ______ __________
Address city state zip
(____)_________________ (____)_________________ (____)_______________________
home phone work phone cell phone
_______________________ ____________________________________ ______________
email address emergency contact name phone #
Pick-Up Authorization
Please list, in order of preference, all persons, (including yourself, and, if applicable, the child’s
other parent/guardian) who are authorized to pick-up your child. Your child will not be released
to anyone not on this list. No changes to this list may be made unless the parent/guardian whose
signature appears below requests such changes in writing. Anyone on the list must be at least 16
years old. I authorize the people named below to pick-up my child from Boondocks Farms camp.
As the parent/guardian, I agree that when my child is picked up or dropped off, by an authorized
person, this person will make sure that a staff person is aware of my child’s arrival or departure, and
will sign my child in and out. I understand that I will be charged a fee of $1 per minute past the end
time of the camp. This is a per child fee. I understand that, in the event my child is not picked up
one hour after camp ends, and all emergency contact attempts have been exhausted, the local police
will be notified and my child may be immediately terminated from the program.
1. ________________________ _____________ _______________ _______________ ______________
parent/guardian’s name relationship home phone cell phone work phone
2. _______________________ _____________ _______________ _______________ ______________
parent/guardian’s name relationship home phone cell phone work phone
CHILD’S PHYSICAL CONDITION AND EXPECTED BEHAVIOR: I hereby declare my child to be physically sound,
having medical approval to participate in the activities during Boondocks Farms Summer Camps. This health
history is correct so far as I know, and my child has permission to engage in all prescribed program activities
except as noted in the special needs section above. I understand that it is my responsibility to promptly notify
Boondocks Farms’ staff in writing of any changes in my child’s health. I certify that my child is amendable to
discipline and free from habits or attitudes, which would make him/her an undesirable participant.
PHOTO & VIDEO PERMISSION: Photos and video footage are periodically taken of participants while at Boondocks
Farms. Please be aware that these photos and video footage are the property of Boondocks Farms and will be
used in Boondocks Farms publications, website and video productions unless you elect not to give permission
for the use of your child’s likeness. I consent to such uses and waive any rights of privacy or publicity I may have
in connection with those uses. Failure to complete this section will be considered permission. _____NO PERMISSION
In the event that a camper is severely injured, ill and/or contagious to fellow campers parents/guardians will be
contacted via phone.
MEDICAL PERMISSION: I hereby give permission to Boondocks Farms to administer the following medication to my child:
Acetaminophen (i.e. Tylenol)_______ NO PERMISSION Diphenhydramine (i.e. benadryl)_______ NO PERMISSION
EMERGENCY AUTHORIZATION: I hereby give permission to the medical personnel attending to my child to order X-rays,
routine tests and treatment for my child, and, in the event I am not able to communicate or cannot be reached in an
emergency, I hereby give permission to the attending physician to hospitalize, secure proper treatment for, and order
injection(s) and/or anesthesia and/or surgery for my child as named above. I will be fully responsible for any costs of such
treatment, even if not covered by insurance.
RELEASE AND WAIVER: In consideration of my child’s participation in the activities at Boondocks Farms and
acknowledging that risk of injury exists,
I HEREBY RELEASE, WAIVE, DISCHARGE, COVENANT NOT TO SUE AND AGREE TO HOLD HARMLESS BOONDOCKS
FARMS OWNERS, AND THEIR OFFICIALS, OFFICERS, MEMBERS INDEPENDENT CONTRACTORS, EMPLOYEES AND
VOLUNTEERS from any and all claims or liability for personal injury or property damage my child or I may suffer directly
or indirectly arising out of or relating in any respect to participating in Boondocks Farms Summer Camps. This waiver
and release of all claims, demands, action, and liability shall include, without limitation, any injury, damage or loss to person
or property which may be (a) caused by any act, or failure to act, by Releasees even if said injury, damage, or loss results from
the negligence of any or all of the above-identified Releasees or (b) sustained by me before, during or after Boondocks Farms
Summer Camps.
I agree to indemnify and hold harmless Releasees from all lawsuits, losses, damages, claims, and expenses, including
attorney’s fees and costs arising from or relating in any respect to my child’s participation in Boondocks Farms Summer
Camps or my breach of all terms and conditions contained in the Boondocks Farms Summer Camps Form. This provision
will apply regardless of whether or not the lawsuit, losses, damages, claims, expenses, attorney’s fees and/or costs arises
out of the negligence of any of the Releasees.
The laws of the State of Indiana will govern any disputes or other matters relating to this Consent and Liability Release.
I certify that I am the parent/legal guardian of this child and that I have authority to make the representation and grant the
authorizations contained herein. I have read and fully understand the terms and conditions of participation in the
Boondocks Farms Summer Camps.
_______________________ ________________________________________ __________________________
PRINTED NAME SIGNATURE DATE
Registration Information |
||||
Participant’s Name (First & Last) |
Birth Date |
Gender |
Date Desired |
Fee |
_________________________________ |
___________ |
__________ |
_______________ |
_______ |
_________________________________ |
___________ |
__________ |
_______________ |
_______ |
_________________________________ |
___________ |
__________ |
_______________ |
_______ |
_________________________________ |
___________ |
__________ |
_______________ |
_______ |
|
|
|
|
|
Total Amount Paid $________
Cash____________Check # __________
(Make checks payable to Boondocks Farms)
I hereby authorize Boondocks Farms to charge the credit card listed below the amount stated below.
Visa/Mastercard/American Express Information – Card may be requested at time of purchase
--- ____________________ _______________ ____________
Expiration Date (mm/yy) Billing Zip
$____________________________________
Amount Paid Today
_____________________________________ _________________________ __________
Cardholder Name (Please Print) Authorized Signature Date
To Submit This Program Registration Form & Payment:
· Mail to: Boondocks Farms, 8001 S. Grant City Road, Knightstown, IN 46148
· On-line registration coming soon at www.boondocksfarms.com, please keep checking.
All campers are expected to exhibit appropriate behavior at all times while participating, watching or attending any program or activity sponsored by Boondocks Farms. The following guidelines are designed to provide a safe and enjoyable summer camp experience for all users. Users shall:
A written or verbal warning will be given to campers if the Code of Conduct rules have been violated.
If there is a second occurrence, campers will be withdrawn from the camp without a refund.
All requests for refunds must be made at least one week prior to the beginning of the camp session. A full refund will only be given when a camp is canceled by Boondocks Farms. All other refunds minus $10 processing fee will be refunded either to the household account or in check form.
A $20 service charge will be assessed on all checks returned due to insufficient funds.
Weather Policy:
Boondocks Farms will do our best to keep track of changing weather conditions both before camp, and during camp. We monitor radar throughout the day to insure camper safety. In the event of rain, campers will be directed to sheltered areas until the weather improves. In case of severe weather, campers will be directed to enclosed shelters for protection. If severe enough weather is predicted prior to the days event, Boondocks Farms will contact campers by 8:00 am to cancel events for the day. (Time missed due to severe weather is not refundable)
What to Wear: Depending on Weather
Boondocks Farms is a functioning farm, so be prepared to get a little dirty. Campers will also do a fair amount of walking so comfortable, fully enclosed shoes are a must. (No flip-flops/open toed shoes) Bring jackets and dress in layers of clothing when weather conditions deem necessary. Campers should be prepared for water related games at the conclusion of camp days, depending on weather.