The Dairy Barn Arts Center · Teen Summer Art Camp 2022 Registration

Please read the Parent-Camper Handbook BEFORE registering your camper.
Summer Art Camp Handbook
Click here for a web link to the handbook published at dairybarn.org and the option to download it as a PDF.

Camper Information

Camper's Legal Name

*

First Name

Last Name

Name Your Camper Goes By

Your Camper's Pronouns

Please Enter Your Camper's Pronouns Here

What grade will your camper begin in the Fall of 2022?

*

In order to attend Teen Camp, campers must be in Grade 8 - 12.

8

9

10

11

12

Camper birth date

*

(mm/dd/yyyy)

Allergy Information

Please use this space to indicate any allergens that affect your camper's health.

Severe Allergy Information

If any of the allergens listed above have a severe health consequence for your camper, checking this box indicates that you would like the Education Director to contact you to discuss appropriate safety planning.

Yes, please contact me.

We welcome children of all abilities and specific needs.

Making us aware of any specific needs your camper may have, will help us ensure a successful camp experience. Please list any conditions or information that will be useful to Summer Art Camp Staff supporting your camper. Included is any prescription or over-the-counter medication your camper will need to have at camp. (Please refer to the Medicine section of the Summer Art Camp Handbook.) Upon entry of information in this field, the Education Director will follow up with you for a conversation about how Summer Art Camp can best provide for your camper.

Camper's Physician's Name and/or Preferred Medical Facility

EX: Holzer

Phone Number of Camper's Physician and/or Preferred Medical Facility

Camper T-Shirt Size

*

Campers receive a special Summer Art Camp t-shirt. Be advised the youth sizes tend to run a little big.

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Parent/Guardian Contact Information

The person listed as Primary Parent/Guardian will receive all non-emergency email communications about Summer Art Camp and their camper's registration.

First Parent/Guardian's Name

*

First Name

Last Name

First Parent/Guardian Email

*

Verify Email

*

First Parent/Guardian Primary Phone

*

Second Parent/Guardian's Name

First Name

Last Name

Second Parent/Guardian Email

*

Verify Email

*

Second Parent/Guardian Primary Phone

Check this box if you would like the Second Parent/Guardian to also receive non-emergency information regarding Summer Art Camp via email.

Yes, please send information to both addresses.

Emergency Contact Information

PLEASE NOTE: Emergency Contact #1 is the FIRST person we will call in case of an emergency and not the Parent/Guardian who registered the camper. If you are registering your camper and intend to be the primary emergency contact, please re-enter your contact information below.

In case of an Emergency the chain of contact will be as follows...
1). Emergency Contact #1
2). Emergency Contact #2
3). Emergency Contact #3 (if listed)
4). Primary Parent/Guardian Primary Phone (if not a previous Emergency Contact)
5). Secondary Parent/Guardian Primary Phone (if listed and not a previous Emergency Contact)

Phone Number of Emergency Contact #1

*

Name of Emergency Contact 1

*

First Name

Last Name

Relationship of Emergency Contact #1 to Camper

*

Phone Number of Emergency Contact #2

*

Name of Emergency Contact #2

*

First Name

Last Name

Relationship of Emergency Contact #2 to Camper

*

Phone Number of Emergency Contact #3

Name of Emergency Contact #3

First Name

Last Name

Relationship of Emergency Contact #3 to Camper

Permissions and Releases

Required

*

Enter your name in the space below, along with today's date. This will act as your legal signature for the following 5 questions.

General Acknowledgement

*

I understand that the name written in the previous space represents me and is my legal signature. I am stating that I am a parent or legal guardian of the camper named in this registration form. I understand that when I click "I agree" in the next questions, I am officially signing my name and agreeing with The Dairy Barn's terms.

I agree

In Case of Injury or Illness:

*

In case of accident or serious illness, I request that the Emergency Phone Numbers in this form be contacted. I give permission for emergency medical treatment including EMS transportation to the nearest medical facility. I agree to assume all costs related to such treatment and I release The Dairy Barn from any responsibility for injury or illness that may occur while my child participates. I hereby give permission for my child to attend The Dairy Barn Summer Art Camp.

I agree

Photography Release

*

The Dairy Barn respects your parental rights. We love Camp publicity, but we understand not all parents are comfortable having their children’s photos published. Photographs may be taken by Dairy Barn staff and used on the Dairy Barn website, Facebook page, or in teachers' personal portfolios or personal social media pages. Photos may also be taken by local news media and used in newspapers and on their websites. If you want to allow photos of your camper to be used, click "Allow". If you do NOT wish you camper to be photographed, click "Don't Allow".

Allow

Don't Allow

Parent and Camper Acknowledgement:

*

By agreeing to this acknowledgement, I state that I have thoroughly read and understand my duties and responsibilities as outlined in the 2022 Summer Art Camp Handbook (linked at the top of this form.) I understand that I will be held to these rules and guidelines and may be charged additionally fees if I fail to adhere to camp pick-up times. I also understand that my child will be held to the Full Value Contract and will be expected to show good behavior and respect for all instructors, assistants and other campers. My child may be dismissed from camp if there are severe behavior and respect issues that consequences and counseling do not resolve. Should this occur, I understand that I will not receive a refund unless at the discretion of the Education Director.

I Agree

Refunds and Cancellations

*

A full refund of the registration fee for a week of camp can only be issued if the Education Director receives notice of request for disenrollment not later than 5:00 PM one week before the published registration deadline. Therefore, FRIDAY, JUNE 24, 2022 (TEEN CAMP). Notice must be given via email to kelly@dairybarn.org or by calling or leaving voicemail in the Education Program mailbox 740-592-4981 Option 1. After these deadlines, disenrollment or missed days or weeks of camp, for any reason, cannot be refunded nor credit offered for future programs.

I Agree

One-time Required Registration Fee

*

$25 - Includes your camper's 2022 Summer Art Camp T-Shirt

Registration

If you would like to become a Household Member of The Dairy Barn for a discounted rate, use the link below.

Join The Dairy Barn Arts Center!

Payment

*

$180 - Teen Art Camp Household Membership Rate

$200 - Teen Art Camp Non-Member Rate

Payment Contact Information

Name on Card

*

First Name

Last Name

Email

*

Verify Email

*

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Summer Art Camp Scholarship Program

We believe that all kids should have the opportunity to attend Summer Art Camp at The Dairy Barn. Every year, your support helps us offer scholarships to families who wouldn't be able to afford camp otherwise. Contact director@dairybarn.org for more information on how to make this happen.

We appreciate your support!

Teen Summer Art Camp 2022 Registration

July 25 - 29, Monday - Friday 10:00 AM - 4:00 PM

Camper Information

Parent/Guardian Contact Information

Emergency Contact Information

Permissions and Releases

Registration

Payment Contact Information