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RR7 Aylmer, ON N5H 2R6
www.farmtowncanada.com
519 773-2292 [email protected]
Dear Parent/Guardian,
We are re-launching our program initiatives for the fall, in order to do so, we are
offering limited summer program spots with the highest level of horse and animal
therapy then ever before! New equine programs have us excited for the great
summer ahead!
SPACES ARE EXTREMELY LIMITED, so please complete and return your
registration package as soon as possible. You may also contact us by phone
(519) 773-2292 with a credit card payment to reserve a spot!
What your participant gets by attending Boys or Girls Horse Programs:
 Interactive day program
 Equine assisted growth and learning stations
 Small group equine activities
 Introductions to horses and safety
 Equine husbandry lessons
 Christian farm heritage tours
 Community guest speakers
 VIP Pre-registration for fall programs
Empowerment, decision making, anger management, esteem building, work skills
training, and social skills development is built into everyday experiences and
activities while at the farm
Looking forward to a fun summer with your child(ren)!
Eieio
Birtha Guenther Program Director for:
Kelly Franklin Executive Director
Farmtown Canada’s Funny Farm Kids
**If another agency or worker told you about our Equine Programs for kids, they may be able
to assist in the application process, payment, or transportation.
1
T-Shirt Order Form
($20.00 no tax)
Sizes: Youth small, medium, large and Adult small, medium, large, xlarge, 2xlarge
Participant Name:_______________________________________________
Week of Camp_________________________________________________
Size (Youth S,M,L Adult S,M,L,XL,2XL Quantity Price per Shirt $20
Total
Final Total
Payment Options
Cash/Cheque (Circle One)
Please only use the Credit card option if you did not include it on page two.
Visa
card#_________________________ expiry date:______
MasterCard card#_________________________ expiry date:______
Name on Card:____________________________________________
Please send this form with payment when you register for camp to:
Farmtown Canada
46703 Mapleton Line, RR7
Aylmer, ON N5H 2R6
Phone (519) 773-2292
Registration
2
Please complete both pages
Note: Incomplete forms will result in delay of your child’s camp registration. Complete both sides in detail. Please complete one
form per participant. Return your Registration with payment options and payment.
Program Participant Information
Name
Birth Day (Y/M/D)
Age at Camp
Gender
Address
City
Postal Code
Phone Number
Doctors Name
Phone Number
Parent 1 / Primary Contact /
Health Card Number /version code
Authorized Pick Up
Name
Name
Address
Address
City
Postal Code
Work Phone
Male/Female
Phone Number
City
Cell Phone
Work Phone
Parent 2/ Secondary Contact/
Postal Code
Phone Number
Cell Phone
Email
Email
Please specify: Both
Custody of Participant
Mother Father Other (Please specify)_________________________________
I understand/permit pictures/video of my child to be taken at programs and used for promotion within Farmtown Canada YES NO
Emergency Contact 1
Name
Work Phone
Cell Phone
Authorized Pick Up
Home Phone
Name
Relationship
Work Phone
Emergency Contact 2
Home Phone
Cell Phone
Relationship
Medical/Other Information
Does your child have any medical conditions we should know about?
Yes
No
Does your child require medication while at program: (original container)
Yes
No
Please specify:
Does your child have any of the following: ADHD ADD OCD
Yes
No
Other:
Does your child have any dietary concerns we should be aware of?
Yes
No
List:
Does your child have any special needs we should be aware of?
Yes
No
List:
Does your child require additional support staff due to special needs?
Yes
No
List:
Does your child have any workers that we have permission
to contact such as CAS workers, counsellors, child workers, etc.?
Yes
No
List Name, Agency, Contact Info
Does your child have any horse experience?
Yes
No
Explain:
Date Received:
Week: Girls/Boys
Office Use Only
By:
Entered Database:
Paid:
Extended Care Y/N
T-Shirt Y/N
By:
Receipt Sent
Owing:
Letter Sent
3
Please check the correct week that your camper will attend
Please contact us asap if you require extended care (it may be available for a fee if there are enough participants).
Note: Please indicate anyone that may be transporting your child for program. Participants will ONLY be released to authorized people
on this registration form. No exceptions
Dates
Pick up /Drop off Times
Ages
June 29—July 3 Girls Only Horse Program Drop Off : 8:45-9:00a.m.
Girls ages 7-12
Pick Up: 3:45 p.m.
*Girls 13-18 with horse/babysitting
experience may call and apply for a
Junior Leader position
Drop Off: 8:45-9:00a.m.
Pick Up: 3:45 p.m.
*Boys13-18 with horse/babysitting
experience may call and apply for a
Junior Leader position
July 6—July 10 Boys Only Horse Program
Boys ages 7-12
Camp Authorization
Campers Authorization Details I permit my child noted above to attend program at Farmtown Canada’s Funny Farm. I
understand that every precaution shall be taken to provide a safe environment and acknowledge the risks and dangers
associated with farm and animal interaction and shall hold no agency, person(s) responsible for accident, injury, death
or dismemberment while at program. I permit my child to participate in the full range of program activities and
authorize the Program Director and her/his appointee in the event of an accident or illness affecting the above child to
authorize on my behalf all procedures including disciplinary measures, removal or limited access to programs resulting
from behaviour, admission to the hospital and necessary treatment therein, as she/he may deem essential for the care
and well-being of said participant and other participants. Such medical action is to be taken only when immediate
contact with the undersigned cannot be made. I acknowledge my awareness that this program is Christian and
presents biblical truths and insights while teaching about animals and environment.
I have read & understood the: a) cancellation policy b) payment c) and understand that any pictures/videos are
used for promotional use by Farmtown Canada and Funny Farm Inc.
Signature of Parent / Guardian_____________________________________________________________
Print Name: ______________________________________Date Signed: ___________________________
From time to time Farmtown Canada’s Funny Farm may use my information on this form to notify the applicant of upcoming events,
volunteer donor opportunities and/or offerings from our other departments that may be beneficial to the applicant. We do not use or disclose,
sell or share information with 3rd parties
Payment Authorization
Payment Information: A $75/participant/week non-refundable deposit is required for registrations. The payment
must accompany a completed registration form and any other forms for items checked off below.
Extended Payment Option: An extended payment plan can be setup by completing the appropriate section below.
A deposits ($75/participant/week) at the time of registration and a method of payment for remaining payment is to be
provided at time of registration. i.e. credit card.
Payment is non refundable: Cancellations & Refunds: All cancellations must be received in writing seven (7)
business days before the affected program session will receive a refund of camp fees, minus the non-refundable
deposit of $75. Any refunds requested after this time will require a medical certificate and are at the discretion of the
agency. NSF Payments: All NSF payments will be subject to a $30 service charge
Every Kid2Camp Fund Farmtown Canada is committed to providing a program experience to families regardless of
ability to pay full fees. If you are able to help another child to come to our programs, please check the section
below with your kind considerate donation to help families in need. Every dollar helps us help kids!
Payment in Full (includes non-refundable deposit) $225
Extended Payment (includes non-refundable deposit) $75 deposit and arrangements to pay prior to June 15/15
Weekly Program Fee $__________ Payment Method:Cash Cheque Visa MasterCard
Extended Care Fee
$__________ Credit Card #_____________________________________ Expiry___________
T-Shirt (s)
$__________ Name of Cardholder:________________________________________________
Signature:_________________________________________________________
Every Kid2Camp
$__________ (Donations over $25 will be receipted at year end for income tax purposes)
Animal Care Donation $__________ (Donations help provide vet farrier care feed and worming)
TOTAL:
$__________ Thank you, your registration confirmation will be mailed.