Registration is to be completed by mail. Allow 2-3 weeks for notification of acceptance or wait list status. COMPLETE BOTH SIDES OF THIS APPLICATION & fill out a separate one for each camper.

Camper’s Name: ______Female: ____ Male: ____

Birth date: ______Age during camp: _____T-Shirt Size/circle one: YS YM YL AS AM AL

Has your child been to our camp before?  YES  NO

Parent or Guardian Name (primary contact): ______

Address: ______City: ______Zip: ______

Daytime Phone: ______Home Phone: ______Cell Phone: ______

E-mail address: ______

Parent or Guardian Name (secondary contact): ______

Daytime Phone: ______Cell Phone: ______

E-mail address: ______

TIME: Camp runs from 9am-1pm / Aftercare runsfrom 1pm-5pm

COST: Creek Camp/ Pioneer Camp/Junior Historian Camp$200/weekIf your child can not attend a full week of Pioneer Camp or Creek camp, you canpay by day- $65/day

After Camp Care$30/day or $120/week if enrolled in summer camps

PIONEER CAMP Camp After Care Y or N Session I June 8th – 12th $______$______

Session II July 6th – 10th $______$______

To pay by day write camp name/session #______

& circle days M T W Th F$______$______

CREEK CAMP Camp After Care Y or N

Session IJune 22nd – June 26th $______$______

Session IIJuly 20th – July 24th $______$______

Session III Aug. 3rd – Aug. 7th $______$______

To pay by day write camp name/session #______

& circle days M T W Th F$______$______


Session IJuly27th – July31st $______$______**Commit to one year of the Junior Historian program and camp is only $75. Otherwise full price is $200.

Buy aPatron or Farmstead Partner membership to receive a 20% discount for one camper.

Adopt An Animal:Your generosity lowers the cost and care to feed our farmstead animals. DonationTotal $______

Total Payment $______


Payment by:  Check (made payable to Heritage Farmstead Museum)

 VISA/ MasterCard# ______Exp. ______

CVV code (last 3 digits on the back of the credit card) ______

Name on Credit Card: ______

Please Mail All Forms and Payment to : Heritage Farmstead Museum Attn: Victoria James – Director of Education

1900 West 15th Street , Plano TX 75075

FRIEND REQUESTWe will attempt to place your child with a friend; however we cannot guarantee that a request will be granted. ONLY ONE REQUEST PLEASE. We thank you for your cooperation. Requested friend: ______

PLEASE NOTE: In the event we are not able to accommodate your first request, we will try to place your child into a 2nd

choice session or on a wait list until space permits. 2nd choice session: ______



If you must cancel your registration you will be eligible for a full refund (minus a $50 processing fee) if the cancellation is made at least 6 weeks before the camp starting date. Cancellations received with less than 6 weeks’ notice will not be eligible for any refund unless a replacement is available to take your camper’s spot.

If you would like to reschedule your camp week, a $25 processing fee will be charged and changes will be accommodated only when there is space available.

I have read and agree to abide by the cancellation policy.


Signature of parent or guardian Date


Child’s Name: ______

Primary emergency contact name: ______

Daytime phone number: ______Relationship: ______

Secondary emergency contact name: ______

Daytime phone number: ______Relationship: ______

Doctor’s Name: ______Doctor’s Phone Number: ______

Does your child have any allergies or medical conditions we should know about? Please specify what your child is allergic to and what reaction is typical. It is especially important that we learn about allergies to bee stings and foods. ______

Will your child be taking any medication while at Camp? If so, please detail. ______


In the event of an emergency, if we cannot reach you, please indicate your permission to authorize emergency care by signing below:


Signature of parent or guardian Date


I authorize that any photographs, motion pictures and/or video recordings taken of my child during his/her participation in a Heritage Farmstead Museum Camp program may be used by the HeritageFarmsteadMuseum for the purpose of promotion in perpetuity. I understand that these photographs, motion pictures and/or video recordings shall be fully owned by HFM and shall make no claim against HFM or the photographer for their use for any reason whatsoever.

It is understood by the party signing this document that the scope of the Consent is as described above, and that there will be no consideration, monetary or otherwise, required from the HeritageFarmsteadMuseum in exchange for such consent.


Signature of parent or guardian Date

CAMPER RULES AND CONDITIONSPlease read with your child/children before registering for Camp

Children should not be dropped off before 8:40am and must be picked up at 1:00pm. If your child is in the After Care Program he/she must be picked up by 5pm.**

Parents will need to sign their child in at drop off time and sign them out at pick up time.

**Late pick ups will be charged $5 per minute, due at the time ofpick up.

All campers will respect each other and staff members. Name-calling, insulting, fighting and violence are never acceptable. Campers will be issued a warning and the parents informed. Repeated warnings will result in dismissal from camp. The Camp Director reserves the right to dismiss any camper, without refund, for reasons of safety or inappropriate behavior.

A parent called for a behavior problem resulting in dismissal must make sure their child is picked up within one hour of being called, or the alternate contacts on the application will be called.

Campers with contagious diseases or conditions, including lice, are not permitted to attend camp.

What to Bring

Children should dress appropriately for an active day, often involving water play and outdoor activities. Wear old tennis shoes & pack any extra items if your child doesn’t want to stay in wet/dirty clothes. No sandals or flip flops.

Shoes should be worn at ALL times. Walking the property in bare feet is not permitted.

Pack a lunch. Unfortunately, we have no meal service.

Bring/apply your own sunscreen & bug spray

An Extra bottle of water is always a good idea.

By registering for this event you are agreeing to abide by the rules and understandings of the Heritage Farmstead Museum Summer Camp and you have discussed these rules with your child/children. Your child/ children may participate in all supervised programs offered through the camp. You understand that attendance to HFM summer camps is based upon mutual respect and consideration between campers and staff.

I HAVE READ AND UNDERSTAND THIS FORM. Parent/Guardian:______Date______

If you have any questions or concerns please contact Victoria James at 972-881-0140 2/2015