Summer Program Registration

Child Name *

First

Last

Child Date of Birth *

Child Age *

Parent/Guardian *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Doctor Name *

Doctor Phone

Emergency Contact *

NAME and RELATIONSHIP to child

Emergency Contact Phone *

Available During the Day

Allergies *

Attire and Belongings: All children should be prepared with long pants, a boot with a heel, a lunch, and water bottle. Children are welcome to bring sneakers. A bathing suit and towel is suggested for hot days when we play water games. Please label all belongings.

I would like to drop off at 8a for $10/day

Yes
No

In the event that I/we are unavailable for the purpose of providing parental consent, I/we hereby authorize a qualified emergency medical technician, physician, or hospital emergency room, as selected by the staff of Red Skye Farm, to provide such hospital care including routine diagnostic procedures and medical treatment to my child. I understand that the consent and authorization herein granted does not include major surgical procedures.

Parent/Guardian Signature *

Please Print Your Name

How would you like to pay?

Pay in Full ($300 per week)
Make a Deposit of $100

Form of Payment

Cash or Check
Credit Card

*Please note: Entering card information does not automatically charge credit card. Card will be charged and confirmation will be sent by email.

Credit Card Number

Expiration

Security Code

Name

Summer Program Registration

110 Hatfield Hill Rd. Bethany, CT

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