Registration

Sunrock Farm Holiday Day Camp - 2011

Check the date(s) for which you are registering:

                                 (All days are 9:30 am to 2:30 pm)

Traditional Camp (ages 5-11 Pre-K (ages 4-5) Youth (ages 12-15)

Mon., Dec. 19___ Fri., Dec. 23___ Wed., Dec. 28___   Mon., Dec. 19___            Wed., Dec. 28___

Tues., Dec. 20___ Sat., Dec. 24___ Thurs., Dec. 29___   Tues., Dec. 20___

Wed., Dec. 21____ Mon., Dec. 26___  Fri., Dec. 30___     Wed., Dec. 21___

Thurs., Dec. 22____ Tues., Dec. 27___ Sat., Dec. 31___        Thurs., Dec. 22___      

Fri., Dec. 23___

Child’s name ( nickname?):_______________________________________________________

Name of parent(s) or guardian(s): _________________________________________________

Address:__________________________________________________________________________

(# and Street) (City, State) (Zip)

Home Phone ____________________ Work phone ________________________

Cell Phone ________________________ Email______________________________

Child’s grade: __________ Child’s age: ________ Child’s date of birth: ______

In case of emergency we call the above phone numbers OR: (please list an alternate)

Name:__________________________ Phone:___________________

Physician's Name: ______________________________ Phone: __________________________

Does the child have allergies, special needs, or other restrictions? Yes No

If “yes”, what are they? (If needed, please use other sheets of paper to describe the restrictions.)

Sunrock Farm reserves the right (1) to refuse registration for health reasons. For example, the farm environment may not be good for

children with severe hay allergies; (2) to cancel camp days due to insufficient registration or extreme weather conditions (with full refund).

A confirmation will be sent to acknowledge your registration.

Camp fee is $50 per day. Please send check/money order (sorry no charge cards) along with this form to:

Sunrock Farm 103 Gibson Lane, Wilder, KY 41076 Phone: 859-781-5502 Fax: 859-572-0260

Refund Policy: There will be a $20 per camper non-refundable processing fee charged for cancellations. The balance of the fee

is refundable ONLY in the case of serious illness or accident (with a physician’s statement), or death in the immediate family.

"I give my child permission to attend winter camp. I agree not to send my child to winter day camp unless she/he is in

good physical condition and has not been exposed to a communicable disease. My child has permission to receive

emergency medical care. I understand that photos of camp activities may be taken during the course of winter camp

and used in farm publications and advertising".

Signature of parent/guardian:_________________________________ Date:______________

Comments & special requests: ___________________________________________________________

FOR OFFICE USE: Date registration form received at Sunrock Farm: ___________ Amount of Check __________

Check number and date __________