2016 Camper Registration Form
Your Camper’s full name/nickname: ___________________ DOB: __________ Age: _____
Please circle: Full Day camp (ages 7-12 – 9am-4pm) Half Day camp (ages 5-7 – 9am-2pm)
Please circle the week(s) of camp you’d like to attend:
*Remember, every SINGLE week is designed so that every camper, no matter the theme, has a great time!
Naturalists
Athletes
June 27 – July1
July 5-8
Farmers In Training
July 18-22
Artisans
Playhouse
July 25-29
August 1-5
Contact Information
__________________________________
Parent/Guardian name
______________________________________
Second contact name
__________________________________
Relationship to camper
______________________________________
Relationship to camper
__________________________________
Mailing Address __send welcome info here
______________________________________
Mailing Address __send welcome info here
__________________________________
Town/Zip Code
______________________________________
Town/Zip Code
__________________________________
Phone (Home/Work/Cell)
______________________________________
Phone (Home/Work/Cell)
__________________________________
Email
______________________________________
Email
Please list two additional emergency contacts below if you cannot be reached:
_________________________________
Name
______________________________________
Name
_________________________________
Phone/Relationship to camper
______________________________________
Phone/Relationship to camper
How did you hear about Camp Bread & Butter? (Please list family name, if applicable, so we can offer their referral discount)
__________________________________________________________________________
Health Note
Please list any allergies, food allergies, health challenges, or concerns.
If your child has extreme food allergies, we will work with you to arrange suitable snacks.
_________________________________________________________________________________________
_________________________________________________________________________________________
Photo Release
______ (Initials) I give Camp Bread & Butter permission to use photos of my child for camp/program
materials
Safety
“I understand that even after responsible precautions have been made, camp activities may involve hazards for
which Camp Bread & Butter cannot be held responsible. In the event that my child becomes ill or injured while
at camp, I authorize the camp staff to seek immediate emergency care. By signing this form, I certify that my
child has health insurance and accident insurance or Medicaid and that in the unlikely event of an accident, I
will provide the Camp Bread & Butter staff with the name of my child’s doctor, carrier and policy number.”
Signature (Parent/Guardian) _______________________________Date _________________
Payment (thank you!)
PLEASE ENCLOSE $100 NON-REFUNDABLE DEPOSIT FOR EACH WEEK OF CAMP. Make checks
payable to Bread & Butter Farm. Or, choose to pay online at www.breadandbutterfarm.com. Thanks!
For full day camp (ages 7-12 – 9am – 4pm): $295/week (4 day week of July 5-8 is $235)
For half-day camp (ages 5-7 – 9am – 2pm): $225/week (4 day week of July 5-8 is $180)
* Please talk to us if your camper is a 7 year old with an old soul and might be better suited for our older fullday program.
Food
While we will be offering freshly harvested and camper cooked snacks twice a day, please send your camper
with a healthy, hearty lunch.
Camp Schedule
Camp is held from 9am – 4pm every day. On Fridays, Campers are also invited to stay through for our Burger
Night (held 4:30-7:30) as long as their parent/guardian arrives by 5pm. Campers who stay will receive a free
meal! Campers’ families will need to pay for their meals. If a parent/guardian cannot come to Burger Night,
please pick up your campers by 4pm on Friday.
Note about camper to counselor ratio:
Please note we are interested in keeping the ratio between camper and counselor low. We are aiming to get to
know each child and for them to deeply engage in all the hands on activities. If your child receives one on one
or additional services in school, we will require you to provide an extra person to attend camp with them.
Please let us know if your child has an IEP or has an aid at school so we know we can expect an additional adult
that you will provide.
Please print and return pages with your deposit or full tuition to:
Camp Bread & Butter, Corie Pierce, 500 Cheesefactory Road, South Burlington, VT 05403
If you have any questions, comments, or concerns, please do not hesitate to be in touch! It is important to
us to make you and your camper as comfortable and excited as possible!
Contact:
Bekah Gordon
[email protected]
802-399-8862
Lastly, a few questions…
Please help us to get to know your camper better. Feel free to use the back of this form if you need more space.
If there is anything else you would like to tell us or talk to us about, let us know!
Why is your child interested in coming to Camp Bread & Butter?
What activities is your child most interested in?
Does your child have experience being on a farm? Please describe.
What strategies does your child employ to deal with conflict?
How can we best engage with your child when she or he is upset?
What are some ways to excite or motivate your child?
Does your child require an aid or IEP at school? Please explain is yes.
Anything else?
Upon receiving your camp registration, Camp Bread & Butter will send out an official welcome letter to you!