Dun Roamin Farm, LLC

_____________________________________________________________
2014 Cricket Camp

Dear Families,
We would like to thank you and your child for the interest you have shown in our camp. You
can rest assured we will do everything within our power to make your childs stay as pleasant as
possible. At Dun Roamin Farm, LLC we offer a setting that enables children to build self esteem,
responsibility, and independence while learning new skills in a positive and interactive environment.
Our main focus for our crickets will be to build confidence, awareness and a concentration in
safety will maintaining a level of responsibility.
The purpose of this packet is to provide you with information concerning our camp operation and
your childs needs for the week. If your child has previously been enrolled in our summer program,
you will notice that we have made some necessary changes. We are anticipating another fun filled,
learning experience for your child.
This year we will be hosting two weeks of cricket camp.
Week 1: June 30th - July 3rd
Week 2: July 7th - July 10th
Each week will have three available sessions to choose from.
Full Session: 9:00 am to 3:00 pm
Morning Session: 9:00 am to 12:00 pm
Afternoon Session: 12:00 pm to 3:00 pm
For the week, you must choose one of the follow: full session, morning session, or afternoon session.
Sessions cannot be alternating for different days.
Meals: Lunch will run from 11:30 to 12:30. This time is set in order to accommodate each of the
sessions. Please bring a packed lunch every day. It is important that your child eats a healthy and
nutritious meal; we will be playing and working hard. Not to mention outside for the majority of the
day. Pack extra snacks, there will be opportunities for snack time throughout the day. It is extremely
important that you drink during the day all day! We will have water available at all times.
Check In:
Full Session & Morning Session: 9:00 AM Monday Thursday
Afternoon Session: 12:00 PM Monday Thursday
Please be sure that your child has all necessary items for their stay here, meaning, rain or shine! If
you are unable to meet this specific check in time please make arrangements with staff prior to the
check in so we can accommodate your needs.

Check Out:
Morning Session: 12:00 PM Monday Thursday
Full Session & Afternoon Session: 3:00 PM Monday Thursday
Please be prepared to pick your child up at the appropriate time every day. If you are unable to do so
it is your responsibility to make other arrangements for your child to be picked up. If you do not
make the necessary arrangements you will be charged an additional fee for the inconvenience.
KEEP IN MIND: We are very accommodating to any specific needs as long as they are
communicated to us in ADVANCED. We cannot help you if we do not know.
Medical: Each child is required to have a completed medical form, consent form, and release form.
Please mail them in promptly. There are three hospitals within 20 miles of our location. Please be
advised that should your child require medical attention while attending our camp, these expenses are
the responsibility of the parent or guardian.
Pictures: There will be snap shots taken throughout the week and will be available to look at on our
Facebook page under Cricket Camp 2014
We look forward to seeing you this summer!!!
Happy Trails,
Dun Roamin Farm, LLC Staff

Dun Roamin Farm, LLC

2014 Cricket Camp APPLICATION
Week One: June 30, 2014 July 3, 2014
Choose 1 of the following:
$350 Full Session: 9:00 am-3:00pm
$225 Morning Session: 9:00 am -Noon
$225Afternoon Session: Noon -3:00pm

Week Two: July 7, 2014 July 10, 2014

Choose 1 of the following:
$350 Full Session: 9:00 am-3:00 pm
$225 Morning Session: 9:00 am-Noon
$225 Afternoon Session: Noon-3:00pm

Camper Information:
Name: _______________________________________________________
Birth Date: ___________________________________________________
Age: ________________________________________________________
Parents or Guardians
Name(s):
Address:
City:

State:

Home Phone:

Cell Phone:

Work Phone:

Email:

ZIP:

Placement is based on a first come first served basis.

Registration fee of $150 must accompany this application. Balance may be paid in increments, with payment in full by time of
check in date. If the opportunity arises for late enrollment, full payment must be made on the date of registration. Refunds will not
be made. Balance may be applied to lessons, must be used within six months from start date of enrolled camp. This registration
becomes effective upon receipt and acceptance of the deposit. Our camp fee is based on our payment schedule. Failure to comply
with the terms of this contract will subject you to cancellation.
Realizing that the orderly operation of the Camp is of the utmost importance, we agree to comply with all Camp rules.

Signature of Parent or Guardian:

Date:

Check List for Day Campers

Please provide name on personal items in case of a mix up
-

Nutritious packed lunch on ice

Nutritious Snacks
Boots (Sneakers are NOT adequate footwear for working with horses)
Jeans or riding breeches for the day

In a duffle bag/backpack:
-

Rain Coat
Sunscreen
Shorts
Sneakers

Optional
-

Certified safety approved helmet

Gloves
Belts

For our young ladies: Hair should be tied back.

Please note: It is important for shirts to be tucked in, in order to prevent a safety hazard.

Camper Health History

Childs Name: ______________________________________________________

The following information is required for child to be admitted into camp

1. Check any special medical condition that your child may have

No specific medical condition

Asthma

Diabetes

Epilepsy seizure disorder

Gastrointestinal or feeding concerns including special diet and supplements

Cerebral palsy / motor disorder

Emotional / behavior disorder including ADD or ADHD

Other condition(s) requiring special care- Specify

_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Food allergies Specify food(s)

________________________________________________________________________________
________________________________________________________________________________
Non-food allergies - Specify
________________________________________________________________________________
________________________________________________________________________________

2. Triggers that may cause problems any health/emotional concerns Specify

_____________________________________________________________________________________
_____________________________________________________________________________________
3. Signs or symptoms to be aware of Specify
_____________________________________________________________________________________
_____________________________________________________________________________________

AUTHORIZATION FOR MINOR'S MEDICAL TREATMENT

Child: ______________________________________________________________
Last
First
MI
Date of Birth: _______________________

Age: ___________

Gender: __________

Doctors Information
Doctors Name: ________________________________________________________________
Doctors Address: ______________________________________________________________
_____________________________________________________________________________
Doctors Office Phone: ____________________ Emergency Phone: __________________
Medical Insurer/Health Plan: __________________________
Policy #______________________
Allergies to Medications: ___________________________________________________________________
Allergies (Other): ___________________________________________________________________
If applicable, please note the conditions for which the child is currently receiving treatment:
_______________________________________________________________________________________________
___________________________________________________________
Note any other significant medical information:
_____________________________________________________________________________
_____________________________________________________________________________

Parent(s)/Legal Guardian(s):
Parent #1:
Name:________________________________________________________________________
Address: ______________________________________________________________________
Home phone: ________________________ Work phone: ____________________________
Cell phone: ____________________________ Pager: ________________________________
Email: ________________________________
Additional Contact Information:_____________________________________________________
_____________________________________________________________________________

Parent #2:
Name:________________________________________________________________________
Address: ______________________________________________________________________
Home phone: ________________________ Work phone: ____________________________
Cell phone: ____________________________ Pager: ________________________________
Email: ________________________________
Additional Contact Information:_____________________________________________________
_____________________________________________________________________________

Emergency Contact in the event Parent(s)/Legal Guardian(s) cannot be reached:

Name:________________________________________________________________________
Address: ______________________________________________________________________
Home phone: ________________________ Work phone: ____________________________
Cell phone: ____________________________ Pager: ________________________________
Email: ________________________________
Additional Contact Information:_____________________________________________________
_____________________________________________________________________________

AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL

GUARDIAN(S)
I do hereby solemnly swear that I have legal custody of the aforementioned minor child.

I grant my authorization and consent for the supervising adult on duty at Dun Roamin Farm, LLC to
administer general first aid treatment for any minor injuries or illnesses experienced by the minor. If the
injury or illness is life threatening or in need of emergency treatment, I authorize the Supervising Adult to
summon any and all professional emergency personnel to attend, transport, and treat the participant and to
issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment,
or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed
physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in
the state in which such treatment is to occur.

It is understood that this authorization is given in advance of any such medical treatment, but is given to
provide authority and power on the part of the Supervising Adult in the exercise of his or her best judgment
upon the advice of any such medical or emergency personnel.

This authorization is effective commencing on the ______day of ____________________, 20_____ and

expiring on the ______day of ____________________, 20____.

______________________________________ ____________
Parent/Guardian Signature
Date