Summer Camp Registration - Apple Ridge Farm

Due to a high volume of registrations Apple Ridge Farm is currently accepting registrations as a “wait list” for summer camp. You will be notified by June 1, 2022 if your student has been accepted for this summer. While we would like to have all students who want to attend academic summer camp be able to do so, we are currently experiencing difficulties with transportation and staffing. Sorry for any inconvenience and check back here for updates.

2022 Academic Summer Camp Registration

Child's First Name*
Child's Last Name*
Session*
Please choose which session you would like your child to attend. The first session is from June 27- July 14. The second session is from July 18 - August 4. You may only choose ONE session.
Gender*
Ethnicity*
Age*
DOB*
Street Address*
City, State*
Zip Code*
T-shirt Size*
Parent/Guardian First Name*
Parent/Guardian Last Name*
Street Address*
City, State*
Zip Code*
E-mail Address*
Phone Number*
Other Phone Number
Number of People in Household*
Please write how many people live in your household full time including yourself.
Total Household Income
Many of our grants require us to report on the income levels of the households that we serve. Please provide your income information below. This and all other information on this form will remain confidential. Thank you.
Total household income in 1 year
How much do you make per hour and how many hours per week on average do you work?
Please write your hourly wage AND how many hours you work, on average, per week.
Permission and Release
*
I, the parent/ guardian undersigned, do hereby agree to allow my child to participate in the Apple Ridge Farm program(s) for the program designated above. I am aware of the rules, regulations, and standards as set by Apple Ridge Farm and the child agrees to abide by them, or to accept dismissal for refusing to follow them.
*
I understand that certain Apple Ridge program activities require participation in exercise, which can, by nature be physically demanding. In consideration of the right to participate in the Apple Ridge Farm program(s), I have and do hereby assume all risk and will hold Apple Ridge Farm and other persons or agencies assisting with the activity harmless from all liability, actions, causes of action, debts or claims which may arise from or in connection with the child’s participation in any Apple Ridge Farm program. The terms hereof shall serve as a release and assumption of risk for the child’s heirs, executors and administrators and for all family members.
*
In the event my child requires emergency treatment, I give permission for Apple Ridge Farm Personnel to transport him/her to an emergency room or physician. I further grant permission for medical personnel to provide treatment.
I hereby irrevocably grant Apple Ridge Farm, Inc. and their designated author(s) and producer(s) permission to record in photograph and/or videotape the likeness of my child/ward.
*
Permission is granted to Apple Ridge Farm, Inc. and any of their designated author(s) and producer(s) to use the likeness of my child/ward and me on the Apple Ridge Farm website on the Internet/World Wide Web.
*
I hereby release Apple Ridge Farm, Inc. and their designated author(s) and producer(s) from any and all claims in the usage of my child/ward’s likeness and image as incorporated and edited into information and promotional materials including digital media, videotapes, books, reports, brochures and pamphlets.
Signature*
Please type your name below in place of your signature
Email
This field is for validation purposes and should be left unchanged.

2022 Academic Summer Camp Registration

Total Household Income

Permission and Release

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