DayCamp

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Riley's Farm Summer Day Camp Guest Registration


Please note: this form will help us begin the registration process.
It does not guarantee admission without a signed reservation contract and payment of fees.
Pay For Your Reservation Here.

              
 
Guest/Day Camper Name
  
 
First Name:
Last Name:
  
   
Age as of June 1, 2010
 
     


   
 
Parent/Guardian Submitting Request



 
  First Name*:
Last Name:
  
  Mailing Address:  
  City, State, Zip  
  Tel. Work
 Occupation:
 
  Tel. Home      
  Tel. Cell      
 
Email: *
    
 
Second Parent/Guardian
(Address & Telephone Necessary Only if Different from Above)
  
  First Name:
Last Name:
  
  Mailing Address:  
  City, State, Zip
 
  Tel. Work    
  Tel. Home      Occupation:  
  Tel. Cell  
  Email:  
 
Emergency Contact Information
  
  First Name:
Last Name:
  
  Mailing Address:  
  City, State, Zip
 
  Tel. Work    
  Tel. Home      Relationship:  
  Tel. Cell  
  Email:  
           
 
Day Camper Insurance Information
  
   
Health Insurance Carrier:
Health Insurance Policy #:
Family Doctor Name:
Family Doctor Phone #
 
     
     
     
 
Person(s) Authorized to Pick up Child Besides Parents
  
   
Person #1
  
   
Person #2
  
   
Person #3
  
 
Dates & Camp Selection
  
   
Camp Week Beginning:
  
   
Number of Weeks
  
   
Program Type
  
   

Please List any specials needs or physical limitation
we should be aware of, including behavior issues and allergies