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Our season has come to a close. Thanks for visiting, and we hope to see you again next season!
Summer Camp Registration
Camper name
Camper age
5
6
7
8
9
10
11
12
Week
Week One: Down on the Farm (June 19-22)
Week Two: Farm Olympics (June 26-29)
Week Three: STEAM on the Farm (July 10-13)
Week Four: Amazing Animals (July 17-20)
Parent / Guardian name
Phone
Email
Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Shirt size
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Emergency Contact
Contact 1
Contact 1 full name
Contact 1 phone number
Contact 1 relationship to camper
Contact 2
Contact 2 full name
Contact 2 phone number
Contact 2 relationship to camper
Additional Information
Who whill pick up the camper?
List any allergies (optional)
List any medications taken in a regular basis (optional)
Does your child have asthma?
Yes
No
Does your child have diabetes?
Yes
No
Do you authorize the use of sunscreen at Camp CCA, and do you authorize Camp CCA staff to assist your child in applying sunscreen?
Yes
No
Does your child require a Epinepherine Auto-Injector to be carried on their person or kept on site? (Optional)
Physician's name (Optional)
Physician's phone (Optional)
In the event of an accident or if your child becomes ill, we will notify who has been listed on the emergency form. If we are unable to contact anyone and we feel that your child needs medical care, do you give us permission to seek medical help?
Yes
No
I hereby grant to Corn Cob Acres, its representatives, and employees the right to take photographs/ videos (through all means including the use of drones) of my child in connection with my child's participation in the activities. I hereby authorize Corn Cob Acres to copyright, use, and publish the same in print and/or electronically. I hereby agree that Corn Cob Acres may use such photographs of my child for any lawful purpose, including but not limited to publicity, illustration, advertising, and Web content.
Yes
No