Contact and Registration Information

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SIMPLY SUMMER. FARM SUMMER PROGRAM. TUES & THURS 9:00 - 4:00

Parent or Guardian Name *

Email *

Phone number *

Child's Name *

Child's Age *

Emergency Contact Name

Emergency Contact Phone Number

Session(s) Attending *

Tuesdays 6/7 thru 8/11

Thursday 6/7 thru 8/11

Both Tuesdays and Thursdays 6/7 thru 8/11

Payment per day *

$35

$40

$45

$50

$55

I have multiple children attending or an extenuating circumstance. Can we talk?

Allergies? (Environmental, Food or Medicine)

Dietary Concerns/Restrictions?

Permission to perform emergency medical intervention? *

Yes

Anything else about anything else?

I attest that the health history and medical information are correct to the best of my knowledge. The person herein described has permission to fully engage in all program activities. I (the parent/guardian listed above) agree that Simply Growing and/or its personnel will not be held responsible for accidents or personal injury arising there from. I give permission for farm staff to provide basic first-aid for minor bumps and bruises, with any specific concerns regarding this noted on this form. EMERGENCY AUTHORIZATION: I recognize that I will be called, followed by the emergency contact if I am not available, in the event of an emergency. In the event I or the emergency contact cannot be reached in an emergency, I hereby give permission to the medical personnel selected by staff to order X-rays, perform routine test, and treat my child as well as give permission to the physician selected by staff to hospitalize, secure proper treatment, and order injection and/or anesthesia and/or surgery for my child named herein. *

Yes. I agree.

Required

I do hereby authorize Simply Growing Farm and its employees to utilize my child’s photographic image for publication purposes (i.e. website, press release, newsletters, program brochures, etc). In giving my consent, I hereby release Simply Growing Farm from any and all liability or responsibility associated with this publication. I understand that I will receive no compensation should any photograph of my child be used. *

Yes. I consent

No pictures of my child, please.

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