Simmons Farm

Little Farmers Camp 2018

Tuesdays 9 AM - 12 PM

July 17:Irrigation - “Pumps and Pipes help farmers get by, when there’s no water in the sky.”

July 24:Farm Animals - “Charlotte says that Bubba is Some Pig”

July 31:Flowers - “We give Flower Power a new meaning”

August 7:Farm Machinery - “John Deere or Case, tractors help a farmer quicken the pace”

August 14: Vegetables - “Knee high by the 4th of July is a rule we live by”

Ages 4-8

Farm Camp Activities:

Hayride & educational tour, pick a crop, art project, playground area and farm snack.

Coordinator: Megan Simmons

For Information call (724) 941-1490.

Registration forms available at:

MEDICAL INFORMATION AND RELEASE

REGISTRATION FORM 2018

MEDICAL INFORMATION (one form may be used for all children in the same family)

Child's First and Last Name______

Child's First and Last Name ______

Child’s First and Last Name______

Address______

Phone 1 ______Phone 2______

M or F

M or F (2nd child)

M or F (3rd child)

Age /Grade______

Age /Grade______(2nd child)

Age /Grade______(3rd child)

Allergies and Symptoms /Medical Needs______

Allergies and Symptoms /Medical Needs______(2nd Child)

Allergies and Symptoms /Medical Needs______(3rd Child)

Children with chronic physical problems must provide pertinent developmental information and must provide any special camp accommodations necessary

______

*Please call Simmons Farm for our policy on providing any necessary/special camp accommodations.

PARENTAL INFORMATION & RELEASE (PLEASE PRINT)

Parent/Guardian First & Last Name______

Address______City ______State ____ Zip______

Contact Phone 1______Contact Phone 2______

Parent/Guardian Email______

Emergency Contact:

Name______Phone______

Relationship to Child______

Medical Release: I (We), the parent(s) or guardian(s) of the above listed child(ren) grant permission for our child(ren) to participate in Little Farmers Day Camp at Simmons Farm and to receive medical treatment if necessary. If I (we) or the listed child care provider or emergency contact cannot be reached, I (we) give our permission to the staff to secure the services of a licensed physician to provide necessary care, including anesthesia, for my child's well-being. I (we) also release and agree to hold harmless Simmons Farm and all its participants from any liability and assume all risk of injury, damage or expenses as the result of participation in activities in Little Farmers Day Camp. Photo/Video Release: I (We) understand that as a participant in Little Farmers Day Camp, my child(ren) may be photographed/videotaped during camp events. I (we) also understand that these may be used in presentation & promotional materials. I (we) release Simmons Farm from any and all liability.

Parent/Guardian Signature______

Date______

2018 Simmons Farm “Little Farmers Camp”

Registration Form

  1. Registration is due by June 30. If past deadline, please call to check on availability.
  2. Please complete the form below. Make sure to enter your child’s name and check the dates he/she wishes to attend.
  3. Enter the total days attending and multiply by $25 per day. Enter total in the space provided.
  4. Please complete and sign the Medical Information Form.
  5. Checks should be made payable to Simmons Farm.
  6. Send Check, Registration Form and Medical Information Form to:

Simmons Farm

Attn. Little Farmers Camp

483 Justabout Rd.

Venetia, PA 15367

Weeks
Child's Name / July 17 Irrigation / July 24
Farm Animals / July 31
Flowers / August 7
Farm Machinery / August 14
Vegetables / Total Days / Days X $25.00





T0TAL DUE

Any questions, please contact Simmons Farm at:

724-941-1490 or

Visit our website for more details on daily activities at:

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