Camp Registration Form (print)

Please print and fill out the form below.  You can email a copy of the completed form to oldtownflowerscu@gmail.com or send it to Old Town Flowers, 708 S Prairie St, Champaign, IL, 61820. If you have a sibling discount, please let me know when you register! Thank you!


Old Town Flowers Camp Registration--Summer 2018
_______ Flower Camp--June 25-June 29 (9am-1pm, M-F), $225/child
_______ Plants + Potions Camp--July 23-July 27 (9am-1pm, M-F), $225/child

Camper Info:
First: ______________________ Middle Initial: ____ Last: __________________________
Birthday: ____/____/__________ Age at time of camp: _________
Street Address: _____________________________________________________________
Town/City: ________________________________ State: ______ Zip: ______________

Parent/Guardian Contact Info:
1. Parent/Guardian
First______________________ Middle Initial: ____ Last: __________________________
Street Address: _____________________________________________________________
Town/City: ________________________________ State: ______ Zip: ______________
Preferred Phone: ______________________________________
2. Parent/Guardian
First______________________ Middle Initial: ____ Last: __________________________
Street Address: _____________________________________________________________
Town/City: ________________________________ State: ______ Zip: ______________
Preferred Phone: ______________________________________

Emergency Contact Information

Emergency Contact #1
First: ___________________________ Last: ______________________________________
Cell Phone: __________________________ Home Phone: __________________________
E-mail: _____________________________ Relation to Camper: ______________________

Emergency Contact #2
First: ___________________________ Last: ______________________________________
Cell Phone: __________________________ Home Phone: __________________________
E-mail: _____________________________ Relation to Camper: ______________________

Medical Release Information
Insurance Information
Policy Number: _____________ Name of Insurance Provider: _________________________
Primary Physician: _____________________________________________________
Address: _________________________________________________________________
Phone: ____________________________ Hospital Preference: _______________________

Please list any medical problems, including any requiring medications (i.e. Diabetic, asthma, seizures, etc.)

        Medical Problem                         Required Treatment          Should a paramedic be called?

________________________      ______________________________         Yes/No

________________________      ______________________________         Yes/No

________________________      ______________________________         Yes/No

Is your child allergic to any type of food or medication?
    Yes        No                If yes, please explain:


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.
                                                                                            Parent/Guardian Initials ___________

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.                                                                                                  Parent/Guardian Initials ___________
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 HERE 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.
                                                                                            Parent/Guardian Initials __________
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.
                                                                                           Parent/Guardian Initials ___________

Old Town Flowers Camp Code Of Conduct
     -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.
Refunds will not be given for behavior-related withdrawals.
     -I have read and discussed this Code of Conduct with my child.
By registering for Old Town Flowers camp, I agree to the terms and conditions as outlined above.
*I agree to the above terms

Signature ___________________________________ Date ________________________