Camp Creation 2022 @ Fiddlewood Farm

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CAMP REGISTRATION IS CURRENTLY CLOSED.

Email *

Which session would your explorer like to attend? *

I'M SORRY REGISTRATION IS FULL FOR CAMP CREATION 2022 AT THIS TIME. PLEASE FOLLOW US ON FACEBOOK AND INSTAGRAM FOR MORE INFORMATION ON ADDITIONAL CAMPS.

Option 2

Explorer's FULL Name (and "Preferred Name") *

Explorer's Age *

T-Shirt Size

Other:

Clear selection

Date of Birth *

YYYY

Guardian Preferred Contact (Name and Number) *

Emergency Contact and Phone # (if Above Unavailable) *

Explorer's Physical Address *

Parent's E-Mail Address (Invoice for Payment will be E-mailed here) *

Health Insurance Carrier and Policy # *

Does your explorer have any allergies (food, medication, environmental) we should be aware of? (If Yes, please specify/ do they need to carry an EpiPen?) *

Can your explorer eat Farm Fresh Eggs from our Chickens while at camp? *

Yes

Family Physician & Phone Number *

Does your explorer use an inhaler? (If Yes, will they carry it with them?) *

If your child does use an inhaler (even occasionally), will they carry it with them?

Does your explorer have any pre-existing medical conditions? (If Yes, what are they?) *PLEASE LIST ALL* *

Please list any comments, questions, or concerns you may have below.

Waiver & Release: Recognizing the possibility of physical injury associated with outdoor activities (climbing, jumping, swinging, etc), I hereby release, discharge, and/or otherwise indemnify Fiddlewood Farm, LLC, Shelly Tyler, and John Mark Tyler and associated personnel assisting staff, including the owners of properties utilized for the programs, against any claim by or on behalf of the explorer as a result of the their participation in the Camp Creation program. As the guardian of this explorer, I request that in my absence, the explorer be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses to perform any diagnostic procedures, treatment procedures, operative procedures, or radiographs of the explorer. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the child. Please electronically sign and date below.

Electronic Signature *

Date of Electronic Signature *

YYYY

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