Please enter the week you have selected to enroll your child/children in our Summer Day Camp program.

Contact person

How did you find us? :

Choose one of the following options:

Customer
Friend
Magazine Advertisement? Which one?

Mag. name
Other?

 

Please provide your information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Cell Phone
Fax
Home Phone
E-mail
Number of children

Choose one of the following options: How do you wish to pay for your Day Camp?

Personal Check payable to Pine View Farm
Cash
Money Order
Credit Card

*If there is any thing you feel we should know about your planned reservation  please let us know:   *It is very important to list for us any known allergies, reactions, medicine or special needs your child/children may have. Please list Emergency Contact information here as well.

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SECURITY Please type in the numbers 1 through 6

  THIS MUST BE ENTERED OR YOU WILL BE DIRECTED BACK HERE TO ENTER IT.

Please read carefully and sign below

 I have read, understand, and agree that by typing my name below in the "Type Name as Signature:" box and submitting this form to Pine View Farm that I  agree to being contacted for reservation confirmation and payment.

Note: Submitting this form does not confirm your reservation.

Type Name as Signature:    

THIS MUST BE ENTERED OR YOU WILL BE DIRECTED BACK TO ENTER IT.