Dickson-Murst Farm Camp

August 3-7, 9 am -3 pm. Entering grades 3rd - 6th. Farm Camp at the historic Dickson-Murst Farm in Montgomery, IL is a full-day camp that introduces children to historic and modern farming methods while celebrating rural lifestyle and cultural heritage! *SUBJECT TO REGISTRATION NUMBERS AND SOCIAL DISTANCING REQUIREMENTS*

Child's Name*

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Nickname (if any)

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Street Address*

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Phone Number*

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Birthdate*

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Entering Grade (Fall 2020)*

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Gender*

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Parent/Guardian Name(s)*

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Daytime Phone*

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Best phone number to reach guardian while child is at camp.

Name(s) of other individuals authorized to pick child up from camp?

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Emergency Contact Name*

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Emergency Contact Relationship to Child*

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Emergency Contact Phone Number*

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Doctor's Name*

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Doctor's Phone Number*

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Any medical conditions we should be aware of?

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(EX: asthma, epilepsy - save allergies for next section)

Does your child have any allergies?

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If yes, please list with severity of reaction.

Please list any dietary restrictions.

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(vegan, halal, kosher, etc.)

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