Child's Name Age Birthdate

Name of Parent/Guardian    

All Phone #(s) 

Street Address  City  Zip  

In case of emergency when you cannot be contacted, list the name and phone number of the person(s) to be called

Name Phone # Relationship

Name Phone # Relationship  

Doctor’s Name Phone #

Allergies to any drugs, foods, insect bites, etc. and the severity of those allergies (ingestion, touch, airborne, rash or anaphylactic reaction)

Current medication and reason(s) for taking

Does your child have a diagnosis, if so what is the diagnosis

What accommodations are required for your child’s diagnosis

In case of emergency if you have a hospital preference please list

I authorize and direct Faith N Friends to call a doctor or other medical personnel and to obtain or provide such other medical services as the farm, in its sole discretion, deems necessary or appropriate in the event of an accident or sickness affecting my child.  I shall be solely responsible for paying all expenses incurred with respect to any such accident or sickness.

I understand that the group will be interacting with animals, participating in walking hikes and tours and games. Except as set forth above, I certify that my child is in good health and can participate in all normal activities of the group.

I understand that reasonable measures will be taken to safeguard the health and safety of the children and that Faith N Friends will notify me as soon as reasonably possible in case of any emergency affecting my child.  However, in the event that an accident or sickness occurs concerning my child, I will hold harmless and release Faith N Friends, the staff of Faith N Friends, and the volunteers from all liability concerning such accident or sickness.