Benton Family Farm

Visit a real 4th Generation working farm that provides a variety of educational farm experiences that are hands on for families,

and SCHOOLS!  Providing farm education for over 23 years.... Meet Mr. Benton who came here in 1941 at ten yrs old.

Camp Form     (trouble printing email me or i can fax it thanks ) Just Highlight and print

                                                             

                                                                           2013      

                                         "Adventure Days on the Farm"              

                                     11896 Old Lexington Pike Walton, KY 41094 

                                                  859-485-7000 cell 859-240-4552  

Email us and tell us what dates you might be interested in first! We may be booked.

Does your child love the outdoors, animals, dirt, and having fun?

                            Bentonfamilyfarm@aol.com 

 Session# 1   July 8-12 ____                    Session # 2 JULY  15-19 ___

 

Session #3  pending please call  July 22-26___      

 

Child’s Name ________________________________________Age_______

 

DOB____/____/_____   Gender_____  

 

Address_____________________________________

 

City______________________  State____ County____

 Zip__________                                      Home/main cell phone#_______________________

 

Email: _____________________________________________

 

Name of School__________________________

LAST Grade COMPLETED:________

Child resides with Mother and Father__       

OR        Mother ___Father____  

 

  Hobbies/clubs/sports:

 

                       ($60.00 due with application NO REFUNDS)

                      (remainder due first day on Monday)

 

FEES      (circle one)   Session # 1, July 8-12          #2   July 15-19      

      

                            9:45-2:45 pm

                

  Total for week  $195.00____

Returning campers $185_____ Campers with siblings email for discount please.

 

Mother Name________________________________________ 

Father Name__________________________________________

 

cell# ________________ Mother

cell#________________  Father

 

Alternate Emergency contact

Name________________________________________ # _____________________________

 

Alternate Emergency contact

Name_________________________________________ # ______________________________

 

In case of emergency, we will call the above phone numbers

 

Does the child have any allergies, special needs, asthma, or any other restrictions? ___yes ___no         Explain 

________________________________________________________________________________________

 

_________________________________________________________________________________________

 

 

Family Dr Name______________________________________ #_____________

 

Benton Family Farm reserves the right to refuse registration for health reasons, as the farm environment

may not be suitable for children with severe hay, bee, wheat and  or food allergies.

 

Make checks Payable to      BENTON FAMILY FARM   11896 Old Lexington Pike        Walton, KY 41094

 

We will contact you with a confirmation letter, information packet and instructions for Farm Adventure Days.

 

I the Parent/Guardian of_________________________ give permission for my child to receive

emergency medical care if so needed.

I understand that photos of Adventure Days may be taken during the week and may be used on website/face book in farm advertising and our publications.

Parent sign__________________________________________

 

Does child medical insurance?   Y/N    Name___________________ 

#___________________________

 

Signature of parent/guardian_________________________________ Date____________

 

Signature of parent/guardian__________________________________ Date____________

 

T shirt size  Circle one _______Child small, med, large, x large 

 OR    

Adult small, med, large, x large,

 

 

Remember they bring their lunch and a water bottle!

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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