Father or Legal Guardian

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother or Legal Guardian

First Name

Last Name

Phone

(###)

###

####

Address (If Different than Above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child #1

First Name

Last Name

Child Resides With:

Father

Mother

Both

Other (Please Explain)

Gender (M/F) - Age - Date of Birth (mm/dd/yyyy)

Child #1 Camp Selection

Child's Medical and Health Information

Doctor's Name, Address, Phone. Dentist's Name, Address, Phone. Hospital of Preference. List any Chronic Medical Conditions.

Child's Food and Other Allergies

Explain any Food and Other Allergies, Physical Limitations, Dietary Limitations, Vision/Hearing Concerns. List any Medications needed during Camp hours and why. Please list any activities that you prefer your child NOT participate in.

Child #2

First Name

Last Name

Child Resides With:

Father

Mother

Both

Other (Please Explain)

Gender (M/F) - Age - Date of Birth (mm/dd/yyyy)

Child #2 Camp Selection

Child's Medical and Health Information

Doctor's Name, Address, Phone. Dentist's Name, Address, Phone. Hospital of Preference. List any Chronic Medical Conditions.

Child's Food and Other Allergies

Child #3

First Name

Last Name

Child Resides With:

Father

Mother

Both

Other (Please Explain)

Gender (M/F) - Age - Date of Birth (mm/dd/yyyy)

Child #3 Camp Selection

Child's Medical and Health Information

Doctor's Name, Address, Phone. Dentist's Name, Address, Phone. Hospital of Preference. List any Chronic Medical Conditions.

Child's Food and Other Allergies

Emergency Contact #1

First Name

Last Name

Relationship to Child

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact #2

First Name

Last Name

Relationship to Child

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Persons Authorized to Pick Up Your Child (Must show photo ID)

Include Full Name, Address, Phone Number, Relationship to Child for Each Authorized Person

Persons NOT Authorized to Pick Up Your Child

Include Full Name, Relationship to Child for Each NON Authorized Person

Authorization for Emergency Medical Care

I hereby give my permission to Rooted Classical Homestead Teachers, Counselors and/or Representatives to call a doctor or emergency medical service and for the doctor, hospital or medical service to provide emergency medical or surgical care for my child, (List Child(ren)'s Name Below). It is understood that the child care provider will make a conscientious effort to locate the parent/guardians and emergency contacts listed on the registration document before any action will be taken. If it is not possible to locate emergency contacts listed treatment will not be delayed. I/we will accept the expense of emergency transportation, medical or surgical treatment. Child(ren)'s Name, Parent/Guardian signatures, Date

Authorization for Applying Sunscreen / Bug Spray

I hereby give my permission to a Rooted Classical Homestead Teacher or Counselor to apply (check one or both below) sunscreen and/or bug spray for my child (List Child(ren)'s Name Below), and I have supplied and labeled the products I would like my child to use.

Sunscreen

Bug Spray

None

Waiver, Release, Hold Harmless and Indemnification Agreement

I/we, the undersigned parents/guardians of: ________________ (herein CAMPER),

in consideration of permission granted to CAMPER by Rooted Classical Homestead (RCH) to participate in its RCH SUMMER CAMP program, hereby give our consent and permission for CAMPER to participate in any RCH SUMMER CAMP activities. I / we understand that said participation is a voluntary activity and that, but for my/our execution of this Consent, Release and Indemnification Agreement, the CAMPER would not be allowed to participate. I/we understand and agree that RCH, its servants, agents, officers, board members, employees, volunteer workers, and all others involved in RCH do not assume any liability for loss or damage to any personal property owned by CAMPER, by us, or any other party and we waive any claim against and release RCH, its agents, servants, volunteers and employees from or for any such loss or damage. I/we also waive and release, to the full extent permitted by law, any claim against RCH, its servants, agents, officers, board members, employees, volunteer workers, and all others involved in RCH from any claim, cause of action or demand I / we may have arising out of, or in connection with, anypersonal or bodily injury, death or property damage which the CAMPER may sustain while participating in RCH SUMMER CAMP and agree to indemnify, save and hold RCH, and those individuals identified above harmless from any claim, demand or cause of action of whatever nature or kind asserted by or onbehalf of CAMPER for any personal or bodily injury, death or property damage sustained by the CAMPER whileparticipating in any and all activities of RCH SUMMER CAMP. All agreements herein are severable, and should any provision be found unenforceable for any reason, all remaining provisions shall remain in full force and effect. By our signatures hereon, we affirm that we have read and fully understand the terms, conditions, releases and waivers set forth.

Media Release

Rooted Classical Homestead (RCH) requests your permission to feature your child in the following ways and without compensation. Please check one below.

I agree to allow RCH to take and use photos, video tape, and/or quotes in RCH publications, website and local media publications.

I do NOT agree to allow RCH to take and use photos, video tape, and/or quotes in RCH publications, website and local media publications.

Would your child(ren) like to attend more than one camp this summer? Please let us know here.

Is there anything else you would like us to know? Do you have any questions?

Dear Registrant,

Thank you for joining the adventure at Rooted Classical Homestead School! Please look for a followup email including payment and camp information in the next few days. Reach out with any questions at 303.325.4689 or kristen@kbadesigns.com. A copy of your submission form by is available upon request.

Camp Registration

Registration

Dear Registrant,

Thank you for joining the adventure at Rooted Classical Homestead School! Please look for a followup email including payment and camp information in the next few days. Reach out with any questions at 303.325.4689 or kristen@kbadesigns.com. A copy of your submission form by is available upon request.

Gratefully,

Rooted Classical Homestead School

The Homestead

Contact Us

We would love to connect with you! How can we help?

send us a message here or Text / Call us @ 303.325.4689

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