Cooking Matters Camp for 5-8th graders
Quiet Creek Herb Farm & School of Country Living
June 9-10, 2014
Parents/Guardians attend 5-6 p.m. for dinner
Student Name ____________________________________________________________
Parent/Guardian Names _____________________________________________________________
Town, State, Zip ________________________________________________________
School Name for 2014-15 ________________________________________________________________
E-mail address for parent and/or student _______________________________________
Grade Level in School for 2014-15 ______________________________________
Emergency Contact Phone (cell # if available) ________________________________
Emergency Contact Name _________________________________________________
Student’s Pertinent Allergies (i.e. food, bees, etc)________________________________
Medication that will be brought to camp _______________________________________
(Refrigeration needed for medication? __________
I (student) ___________________________ am committed to attend the two days of herb camp June 9-10. Each day, I (parent/guardian) _______________________ will attend the dinners at 5 p.m. We grant permission for photographs and video to be taken of student.
Signature Student ________________________________________________________
Signature Parent/Guardian __________________________________________________
Applications due June 1, 2014 with enclosed $15 check refundable registration deposit , if child attends both days check will be returned (make checks to Quiet Creek Herb Farm). .
Send application and check payable to Quiet Creek, 93 Quiet Creek Lane, Brookville, PA 15825
Please pack a lunch for each day and bring a water bottle, dinner will be provided.
Questions? Call Claire at 849-9662 or e-mail at firstname.lastname@example.org