SIMPLY FAMILY FUN " Down on the Farm"
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                                                        OWEN FARM SUMMER CAMP 2019
                                                    434-685-4123 or

NAME: __________________________________________________AGE_______SEX______________
PHONE NUMBER/HOME_____________________WORK________________CELL__________________
PARENTS NAMES______________________________________________________________________
EMAIL ADDRESS_______________________________________________________________________
NONE ALLERGIES______________________________________________________________________
EMERGENCY CONTACT/NAME AND PHONE NUMBER_________________________________________
Please mail or bring completed form along with $42.50 non-refundable deposit to Owen Farm, 1668 Silver Creek Road, Danville, 24540. Cost of camp for one week $160 plus $2.50 sales tax. (Sibling discount is $135 plus $2.50 sales tax). If your child would like to attend more than one camp the cost is $145.00 per week plus $2.50 sales tax. Please check camp dates that you would like for your child to attend. (The cost of the first camp is $162.50and following camps would be $147.50). Daily camp prices are $42.50
#1 June 3-7_____ #2 June 10-14______ #3 June 24-28______ #4 July 8-12_______ #5 July 15-19 _____

I give my child permission to attend and participate in all activities during farm camp at Owen Farm. I understand that all equestrian activities and zip line activities are excluded from liability insurance and I take on the full responsibility of allowing my child to work with and ride the horses and ride the zip line on Owen Farm. I have discussed with my child about the following the rules while at the farm and he/she understands there will be consequences for not following the rules. I also understand that by signing this form that I agree to allow Owen Farm to print and publish pictures taken of my child during Farm Camp. Camps are held rain or shine.

Parent Signature

Childs Signature 

List of People that my child/children may ride with