ROUNTON
farm
10155 R A P I D A N R O A D
O R A NG E , VA 22960
www.rountonfarm.com
ROUNTON FARM SUMMER CAMPS
REGISTRATION FORM
Student Name: ______________________________________________
Parent/Guardian Name(s):_______________________________________
Gender: M / F
Birth Date: ____________________________
Address: __________________________________________________
__________________________________________________
Home Phone: _______________________________________________
Cell Phone: ________________________________________________
Email Address: ______________________________________________
Current School: _____________________________________________
Grade level for Fall: _________
Does your child require special services during the school year?
Yes _____
No _____ If so, please explain.
_________________________________________________________
_________________________________________________________
Phone where parent/guardian can be reached during class time:
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_________________________________________________________
Emergency contact person(s) and phone(s)-other than parent/guardian:
_______________________________________________________
_______________________________________________________
Is there any medical condition we need to be aware of including allergies
of any kind? Yes _____ No _____
If so, please explain:________________________________________
_______________________________________________________
_______________________________________________________
Physician’s Name: __________________________________________
Physician’s Phone: __________________________________________
If parents or above Emergency contact persons cannot be reached, I give
my consent for Rob Pitera and/or Ellen Pitera to call the physician listed
above and to follow physician’s instructions. In addition, I have read and
understand all rules and procedures associated with Rounton Farm
Summer Camps.
_____________________________________
PARENT/GUARDIAN SIGNATURE
************************************************************************************
Total fees are required at time of registration.
Make payments on our website using Pay Pal, send in a check made
payable to Rounton Farm Summer Camps or pay with your credit card in
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person. ONCE ALL NECESSARY PAPER WORK AND FEES ARE
RECEIVED, YOUR CHILD WILL BE ADDED TO THE FINALIZED
Class Selection:
Place an  by each class that your child will be attending.
3/4yr. olds
 Buggin’ Out - June 15th-19th $110
 Silly Science - June 22nd-26th $110
 Farm Safari - June 29th-July 3rd $110
PreK-3rdGrade
 Silly Science- June 15th-19th morning $130
 Water World- June 15th-19th afternoon $130
 Craftastic- June 15th-19th afternoon $140
 Outdoor Fun June 22nd–26th morning $130
 Jr. Engineers June 22nd–26th morning $130
 Animal Kingdom- June 22nd–26th afternoon $130
 Edible Adventures- June 22nd–26th afternoon $130
 Into the Wild- June 29nd–July 3rd morning $130
 If You Build it…- June 29nd–July 3rd morning $130
 Movie Making- June 29nd–July 3rd afternoon $130
 Pintsize Picasso- June 29nd–July 3rd afternoon $140
Total Fees: ______________
**Register by March 1st for a $10 refund (per camp): ________**
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Lunch Break ($25 per week):_________
Pre Camp ($25 per week):___________
Photo Release Form for Campers:
Parent Permission: Photos and video clips will be taken
during Rounton Farm Summer Camps and may be used
in marketing materials for Rounton Farm. By signing
below, I give permission to record my child’s image,
voice, statements and/or writing to Rounton Farm in
Orange, VA. I further irrevocably grant to Rounton
Farm, its advertisers, clients, agents, successors and
assigns, unrestricted rights to use the above
mentioned sound, still, or moving images in any medium
for educational, promotional, advertising, or other
purposes without limitation consistent with the
mission of Rounton Farm. I agree that all rights to the
sound, still, or moving images belong to Rounton Farm.
I voluntarily waive the right to inspect or approve such
images. This release is effective on the date written
below and will remain in effect indefinitely.
__________________________________________ Parent/Legal
Guardian Signature
________________________________________
____________
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Print Name
Date
______________________________________
Child’s Name
farm
ROUNTON
10155 R A P I D A N R O A D
O R A NG E , VA 22960
www.rountonfarm.com
Rounton Farm Summer Camps
Student Expectations:
Supplies: All students for each Camp are required to
bring a backpack or bag every day containing; a healthy
snack, a change of clothes, a full water bottle and
lunch for full day camps.
Clothing: All students are expected to dress
appropriately for inside and outside activities in all
weather conditions.
Toys/Electronics: NO toys or electronics are
necessary. You may leave them all at home.
Behavior: All students are expected to adhere to the
Golden Rule, “Treat others the way you want to be
treated.”
We have read the Rounton Farm Summer Camps Student
Expectations and by signing this form the student promises to
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follow these guidelines and the parent promises to support
them in doing so.
Student:_____________________________
Parent/Guardian:_______________________
Date:________
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