Little Farmer’s Farm School

313 Cedar Street   Ashland, MA 01721    508-395-8345

(circle) M T W TH F                                   

Child’s Name ___________________________________________   Nickname _____________

Child’s age in September _____ years _____ months      Birthdate ______________  Sex _______

Home Address ________________________________________  Phone __________________

Town ________________________________________________  Zip Code _______________

Parent/Guardian Information:

Parent/Guardian’s Name __________________ Parent/Guardian’s Name ____________________

Relationship to child _____________________ Relationship to child _______________________

Home Address _________________________ Home Address ___________________________

Home Phone ___________________________ Home Phone _____________________________

Cell Phone _____________________________ Cell Phone ______________________________

Occupation ____________________________ Occupation _____________________________

Business Address _______________________ Business Address _________________________

Business Phone _________________________ Business Phone ___________________________

Email Address _________________________  Email Address ___________________________

Can your information be included on a class list  ____ yes  ____ no   Omit ____________________

Names and ages of siblings and household members _____________________________________

___________________________________________________________________________

People who are authorized to pick up your child:

Name ______________________________________ Phone ___________________________

Name ______________________________________ Phone ___________________________

ALLERGIES __________________________________ Child’s Physician ___________________

                                                                    Physician’s Phone ___________________

Additional Information (special accommodation requests, identified special needs, developmental support needed, etc)

____________________________________________________________________________

____________________________________________________________________________

*PLEASE send in or email a copy of your child’s annual physical form

Adventures in Learning

Little Farmer’s Farm School

WHAT I NEED (label everything)

• Backpack
• Snack and a drink
• Extra clothing
• Clothing for weather (hat, raincoat, boots, mittens, snow pants, etc)
• Hand sanitizer
• Water bottle

Additional Items (not required)

• Insect repellant wipes for children to use independently
• Food scraps (banana peels, watermelon rinds, apple cores, peels, ANY fruit or vegetable no longer good for human consumption NO AVOCADOS (poisonous)

Please cut along line and return with your child on the first day of school

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My child/ren has permission to participate in this program and I have completed and returned the google registration form and registration packet (application, developmental history, annual physical) with all required information. I authorize Courtney Arseneault and the staff at Adventures in Learning Inc to care for my child’s needs while attending Little Farmer’s Farm School.  I understand this program is completely outdoors.

Child’s name: _______________________________________________________________

• My child has permission to participate in all farm based activities including interacting with animals, exploring wooded and garden areas, using tools, and all school based activities.  If you opt your child out of a farm based experience please indicate below (i.e collecting eggs)

____________________________________________________________________

Medications: ___________________________________________ I give consent to administer in the event of an emergency      *Medication  EEC form must also be completed

I give Courtney Arseneault permission to administer first aid and have my child transported in a health emergency.

Insurance information:

Emergency info at a glance:

Emergency Contact and number ___________________________________________________________

I have read all related information for Farm School (Family Handbook) and agree to policies and my tuition payment schedule

Parent/Guardian’s name, signature, and date ___________________________________________