Summer Day Camp Registration Packet

Please Select Activity You Are Registering For:

Little Sprouts - Session 1 (June 18-21)
Gardeners - Session 1 (June 25-28)
Gardeners - Session 3 (July 16-19)
Gardeners - Session 2 (July 23-26)
Jr. Farmers - Session 1 (July 9-12)
Jr. Farmers - Session 2 (July 30-August 2)
Creek and River Exploration (June 22)
Creek and River Exploration (July 13)
Kids in the Garden (June 29)
Kids in the Garden (July 20)
Art and Nature (July 6)
Art and Nature (July 27)

Camper Name*

First Last

Gender*

Male
Female
Non-conforming

Birth Date*

Age During Camp

Grade Level (in Fall 2024)

Parent or Guardian Name (Primary Contact)*

First Last

Address (Primary Contact)*

Street Address Address Line 2 City State ZIP Code

Phone (Primary Contact)*

Alternate Phone (Primary Contact)

Email (Primary Contact)*

Enter Email Confirm Email

Parent or Guardian Name (Secondary Contact)*

First Last

Address (Secondary Contact)

Street Address Address Line 2 City State ZIP Code

Phone (Secondary Contact)

Alternate Phone (Secondary Contact)

Email (Secondary Contact)

Enter Email Confirm Email

Medical Release Information

Primary Emergency Contact*

Relationship

Phone*

Secondary Emergency Contact*

Relationship

Phone*

Doctor's Name*

Doctor's Phone*

Does your child have any allergies, medical conditions or other special needs?

It is especially important for us to know about bee sting and food allergies (check YES and list below).

Yes
No

Specify allergies, medical conditions and typical reactions.

Does your child have any food sensitivities, restrictions or intolerances?

ATTENTION! We cook and/or serve snacks every day so this is important.

Yes
No

Details about any food sensitivities, restrictions or intolerances.

Will your child be taking medication while at Soil Born Farms?

Yes
No

Details about any medications taken while at SBF.

Any medication your child brings to camp should be in a ziplock bag clearly labeled with their name.

Does your child have any special behavioral needs or anything else that we should be aware of? (i.e. physical limitations or challenges, attention difficulties, Autism Spectrum Disorder, dyslexia, social anxiety, etc.)

We strive to create an inclusive environment for participants of all abilities and backgrounds. It is important for our planning that we be aware of the needs of our campers.

Yes
No

Details about special behavioral or other needs.

For Little Sprouts Campers: Can your child use the restroom without assistance?

Yes
No

Emergency Authorization*

In the event of an emergency, if we cannot reach you, indicate your permission to authorize emergency care by checking YES.

Yes
No

Emergency Authorization Date*

Pick-up Authorization

Any person, other than the authorizing parent, who is picking your child up must be listed on this form and must show identification at pick-up. If you want your child to be able to sign themselves in and out, please list their name on the form as well. Child will not be allowed to leave with any person without written authorization from parent or authorized representative.

Pick-up Authorization*

Indicate your permission to authorize the following people to pick-up your child by checking YES.

Yes
No

Pick-up Authorization Date*

Names of Persons Authorized to Take Child from Facility

Authorized Person 1

Cell # (Person 1 )

Work # (Person 1 )

Authorized Person 2

Cell # (Person 2 )

Work # (Person 2 )

Authorized Person 3

Cell # (Person 3 )

Work # (Person 3)

Cancellation Policy

If you must cancel your registration you will be eligible for a full refund (minus a $25 processing fee for camps, and $5 fee for Saturday Kids Activities) if the cancellation is made at least 3 weeks before the camp starting date. Cancellations received with less than 1 weeks’ notice will not be eligible for any refund unless a replacement is available to take your camper’s spot.

Cancellation Policy Signature*

Please indicate that you have read and agree to abide by the cancellation policy by checking YES.

Yes
No

Cancellation Policy Signature Date*

Waiver and Liability Agreement

Soil Born Farms (“SBF”) is a nonprofit organization whose mission is to empower youth and adults to discover and participate in a local food system that encourages healthy living, nurtures the environment and grows a sustainable community. By signing below, I, the parent or legal guardian agree that:

1. Policies and Safety Rules. For my safety and that of others, I will comply with SBF’s policies, safety rules and its other directions for all Summer Day Camp activities that are communicated on arrival to the farm, on signage throughout the farm, and from the SBF Summer Day Camp (“SDC”) Staff. I will supervise any child or other person for whom I am responsible before and after camp. If I become aware of any hazardous condition or danger at an SBF program site, I will alert SBF.

2. Awareness and Assumption of Risk.I understand that my child’s activities with SBF have inherent risks that may arise from SBF’s operations, my/child’s own actions or inactions, or the actions or inactions of SBF, its directors, officers, employees and agents, other volunteers, and others present at SBF farm. These risks may include, but are not limited to: dangers and conditions inherent to farm property and other program sites, including bees, snakes, animals, poison oak, uneven terrain, allergens, and use of tools, and farm equipment; weather; physical exertion; and travel to and from SBF program sites. I assume full responsibility for any and all risks of bodily injury, death or property damage caused by or arising directly or indirectly from my/my child’s presence at SBF or participation in SBF activities, regardless of the cause.

3. Waiver and Release of Claims. I waive and release any and all claims against: SBF; the owner or owners of premises on which SBF programs take place including owners of sites for gleaning activities (collectively, “landowners”); other tenants at SBF’s or landowners’ premises; the County of Sacramento (the “County”); and SBF’s, landowners’, the County’s, and other tenants’ directors, officers, agents, employees, volunteers, and affiliates (collectively, the “Released Parties”), for any liability, loss, damages, claims, expenses and attorneys’ fees (collectively, “Liabilities”) resulting from death, or injury to my person or property, caused by or arising directly or indirectly from my presence at a SBF program site or participation in SBF activities, regardless of the cause and even if caused by negligence, whether passive or active. I agree not to sue any of the Released Parties on the basis of these waived and released claims. I waive the protections of Section 1542 of the California Civil Code, which provides that a general release does not extend to certain claims not known to me at the time I signed this waiver and release. I understand that SBF would not permit my child to participate in Summer Day Camp without my agreeing to these waivers and releases.

4. Medical Care Consent and Waiver. I authorize SBF to provide to me and my child first aid and, through medical personnel of its choice, medical assistance, transportation, and emergency medical services. This consent does not impose a duty upon SBF to provide such assistance, transportation, or services. In addition, I waive and release any claims against the Released Parties arising out of any first aid, treatment or medical service, including the lack or timing of such, made in connection with my/my child’s activities with SBF.

5. Indemnification. I will defend, indemnify, and hold the Released Parties harmless from and against any and all Liabilities, including without limitation, Liabilities arising from any injury, property damage, or death that may be suffered by me, my child, or any person in a relationship with me or any other third party, which may arise directly or indirectly from my SBF activities, except and only to the extent the liability is caused by the gross negligence or willful misconduct of the relevant Released Party.

6. Confidentiality. As a parent or legal guardian of a SDC participant, I may have access to SBF confidential information. At all times during and after my participation, I agree to hold in confidence and not disclose or use any such confidential information except as required in my SBF volunteer activities or as expressly authorized in writing by SBF’s Executive Director.

7. Publicity. I consent to the unrestricted use in any form of any photographs, interviews, film, videotapes, other visual or auditory recordings, in any other medium, including the Internet, of me and my child that the Released Parties or others may create in connection with my/my child’s participation in SBF Summer Day Camp activities. I waive any right to inspect or approve the finished product and acknowledge that I am not entitled to any compensation for creation or use of the finished product.

Photo Release*

Yes, SBF may use photos of my child
No, SBF may not use photos of my child

Waiver Signature*

Please indicate that you have read and agree to abide by the Waiver and Liability Agreement by checking YES.

Yes
No

Signing Parent/Guardian Name*

Waiver Signature Date*

Comments

This field is for validation purposes and should be left unchanged.

Summer Day Camp Registration Packet

Contact Information, Medical Release, Authorizations and Waiver

Medical Release Information

Pick-up Authorization

Cancellation Policy

Waiver and Liability Agreement