1. Parent / Guardian Information

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Welcome to our online health form! We hope this survey will simplify and streamline the registration process. On the first day of programming we will ask for your signature on a document created by your responses here. This first page collects parent / guardian information that will apply for each child you register. The remaining pages collect specific health information for your child(ren).

* 1. Parent / Guardian Information. Under email address, please confirm the address where you received your enrollment notification.

* 2. If parent / guardian cannot be contacted in an emergency, please contact:

* 3. Health Insurance: to expedite care for your child(ren), we request but do not require the following information:

* 4. Do you grant permission to publish in print, electronic, or video format, the likeness or image of your child(ren):

  Yes No
for the general promotion of Shelburne Farms and its programs?
for the use on a private site such as snapfish or shutterfly with viewing permission granted to families from your child(ren)'s program(s)?

* 5. Do you give permission to transport your child(ren) in camp vans and wagons?

* 6. Will you be available on the first day of programming to sign a document created by your responses here?