Online Camp Registration Form

Please fill out the form below and hit the "submit" button at the bottom. If you would prefer to fill out a paper copy and mail it to me, please go HERE

Camper Information *
Camper Information
Birthday *
Parent/Guardian Contact Info
1. Parent/Guardian *
1. Parent/Guardian
Preferred Phone *
Preferred Phone
2. Parent/Guardian
2. Parent/Guardian
Preferred Phone
Preferred Phone
Emergency Contact Info
Emergency Contact #1 *
Emergency Contact #1
Preferred Phone *
Preferred Phone
Alternate phone (home/cell)
Alternate phone (home/cell)
Emergency Contact #2 *
Emergency Contact #2
Preferred Phone *
Preferred Phone
Alternate phone (home/cell)
Alternate phone (home/cell)
Medical Release Info
Primary Physician *
Primary Physician
Address *
Phone *
Medical Services Consent *
I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorized the calling of a doctor and/or the providing of necessary medical services by Certified Emergency Personnel.
Medical Expenses Consent *
I understand that Old Town Flowers and/or Joan Jach will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as a parent/guardian.
Terms and Conditions--To guarantee a place in the desired week, payment must be made in full at the time of registration. Payment can be made online at the link below or in person. Checks can be made to Old Town Flowers.
Cancellation/Refund Policy--Your registration cost, minus a $50 administration fee, will be refunded if you decide to cancel on or before: -June 8, 2018 (Flower Camp) -July 6, 2018 (Plants + Potions) *No refunds will be given after these dates.
Photo Consent *
I hereby authorize Old Town Flowers and/or parties designated by Old Town Flowers to use (for non-commercial purposes only) any images of me or my children photographed at Flower Camp or Potions + Plants Camp. I understand that if I have any questions regarding the use of such images by Old Town Flowers, I may contact Joan Jach at 217.714.3076.
Field Trip Consent *
I hereby give permission for my child to take walks around 708 S Prairie St., where the camp is located. In addition, I give permission for my child to visit The Idea Garden (1800 S Lincoln Ave, Urbana, IL 61801) on Friday June 29 during the Flower Camp week.
-Campers will treat their fellow campers, gardeners, and instructors with respect. -Campers will treat the plants, flowers and garden areas we visit with respect. -Campers will stay with the group. Please read and discuss these expectations with your child. In the event that your Camper does not follow the Code of Conduct, or his or her behavior endangers other participants or interferes with the my ability to provide programming, I will inform the parent/guardian at pick-up or through a phone call. If a second incident occurs, parents may be asked to withdraw the camper from the program.
Code of Conduct Acknowlegement *
Agreement/Electronic Signature *
By checking the box below, you are submitting your electronic signature in agreement to the terms and Conditions of Old Town Flowers camp program/s.