2023 Academic Summer Camp Registration Child's First Name*Child's Last Name*Gender*FemaleMalePrefer Not To SayEthnicity*AsianBlack/ African AmericanHispanic/Latino AmericanIndian/ Alaskan NativeNative Hawaiian or Other Pacific IslanderTwo or More Races (Multi-Racial Individuals)WhiteAge*DOB*Street Address*City, State*Zip Code*T-shirt Size*Youth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult X-LargeParent/Guardian First Name*Parent/Guardian Last Name*Street Address*City, State*Zip Code*E-mail Address*Phone Number*Other Phone NumberNumber of People in Household*Please write how many people live in your household full time including yourself.Total Household IncomeMany 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 yearHow 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 agree*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. I agree*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 agreeI 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. I agree*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 agree*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.I agreeSignature*Please type your name below in place of your signatureCommentsThis field is for validation purposes and should be left unchanged.
