Summer Camp Registration Form

Please complete the following form which will register your child for our Summer Farm Camp.

Complete payment either via:
*Paypal – you will automatically be taken to a PayPal page at the end of the form
*Credit Card – call our Office Manager 570-992-6161 to complete a credit card payment
*Mail – mail a check with participant name(s) in note section made payable to QVLHF to:
Quiet Valley Living Historical Farm
357 Quiet Valley Road
Stroudsburg, PA 18360

Costs are:
Farm Explorers (completed 3rd 4th 5th grade) $110 Non-members $100 Members
Nature Explorers (completed Kgart 1st 2nd grade) $70 Non-members $60 Members
Thursday Explorers (ages 11-14) $110 Non-members $100 Members

Register Participant For:
 Farm Explorers July 11-15 Nature Explorers 1 July 18-22 Nature Explorers 2 -Aug 1-5 QV Explorers Thursdays July 7-Aug 11

Contact Info:

Emergency Contact Info:

Additional Info:

List any concerns that we should be aware of (physical restrictions, emotional issues, allergies etc: :

Medical Insurance Information (Company name, policy number and any other necessary information) :

If you anticipate your child will be absent on any dates, please list:

We authorize Quiet Valley to take photographs of my child, said images for sole use of Quiet Valley.
 Yes No