SPRING Farm Camp Registration Form

Spring Farm Campers are ages 5 to 9.

Please gather and have the following information to hand before you begin, unfortunately the form doesn’t allow for saving and completing later:

Childs date of last Tetanus vaccination/booster (DTP/DTap on immunization record)
If applicable, Childs medication details
Physicians Name and Phone number
Details for 2 emergency contacts

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT
Your Child's Name (Camper):*
First Last
Consent for Emergency Medical Treatment*
I, the parent (or guardian) of the above-named camper, do hereby give permission to the Henny Penny Farm staff to secure medical treatment for my child if necessary. In the event of accident or injury, when parent, legal guardian or an emergency contact are not available, I give my permission to Henny Penny Farm to procure medical attention.
I have read and understand the above.
Consent status:*
- I give consent and agree to the above
- I do not consent to the the above
Parent / Guardian Name*
Prefix First Last
Parent / Guardian Signature:*
Date Signed*
Month
Day
Year

PHOTO RELEASE
Your Child's Name (Camper):*
First Last
Photo Release Statement:*
Subject: 2024 Henny Penny Farm Camps and Programs

Location: Henny Penny Farm, 673 Ridgebury Rd, Ridgefield CT 06877

I grant to Henny Penny Farm, its representatives and employees the right to take photographs of my child in connection with the above-identified subject. I authorize Henny Penny Farm, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Henny Penny Farm may use such photographs of my child with or without the child’s name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
I have read and understand the above.
Permission to use photographs:*
- I give consent and agree to the above
- I do not consent to the the above
Parent / Guardian Name:*
Prefix First Last
Parent / Guardian Signature:*
Date Signed:*
Month
Day
Year

CAMPER INFORMATION