Wild Goose Farm Theater/Art Week Registration Form


Youth's Name___________________________________________Boy/Girl (circle)


Birth Date_____________________ Age on June 1st__________


Parent or Guardian Name(s)___________________________________________________


Home Address_______________________________________________________________________


City___________________State ____Zip_________   


Home Phone___________________________  Work  Phone__________________________________


Cell Phone____________    Email____________________________________


What is the best way to reach you?  _____________________________________________


Payments and Timing:


$475 per child ($425 for family members of the farm).  A $50 nonrefundable deposit holds your space. The deposit is due by Saturday, March 26th, 2016. The balance is due by April 15th, 2016. If you are interested in a tuition reduction in exchange for work hours at the farm (i.e. group work days, garden help, etc) during the summer, let us know and we'd be happy to work something out.


Checks can be made out to Wild Goose Farm and mailed with this form to Wild Goose Farm, 2099 Beaver Run Rd. Lewisburg, PA 17837 or payment can be sent via paypal on our website.


Upon receipt of deposit, we will send confirmation and a list of what to bring. All participants are required to verify that they have had a physical within 2 years prior to the start of camp.


The balance and completed health form are due on or before April 15th.


CANCELLATION/REFUND POLICY: Sorry,  no refunds or reductions after May 1st unless


a) we are notified at least 3 weeks before camp AND b) are able to fill your space. If those two conditions are met, payment will be refunded minus the nonrefundable deposit. You are, however, welcome and encouraged to transfer your space to another child if your child is unable to attend.


I have read and agree to the payment terms and cancellation/refund policy above.


_______________        ______________

   initials                      date


Anything special you want us to know about your child? (food allergies, fears, favorite activities)








Photo release


If we get an incredibly cute picture of your child having fun at the camp, may we have your permission to use it in brochures, website, newspaper etc. to tell other kids about our farm?


For yes, please sign below...and thanks!






This form is intended to prevent persons from suing for damages in certain circumstances. The undersigned, on behalf of their minor child noted below, has enrolled their child in a week of activities at Wild Goose Farm operated by Kathy and David Kristjanson-Gural of Lewisburg, Pennsylvania. As a condition of participation, the undersigned agrees that on behalf of said participant and themselves individually, they agree that:


1. THEY HEREBY RELEASE, WAIVE AND DISCHARGE AND AGREE not to sue David and Kathy Kristjanson-Gural, their employees and volunteers FROM ALL LIABILITY for any loss or damage, and any claims or demands therefore on account of injury to the person of the undersigned, arising from participation the week of activities at Wild Goose Farm.


2. THEY ASSUME FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY due to any negligence of David and Kathy Kristjanson-Gural, their employees and volunteers.


I understand that this is a RELEASE OF LIABILITY and that I have read this RELEASE before signing.




Name of Registered Camper___________________________________


Name of Parent/Guardian________________________________________________


Signature of Parent/Guardian_____________________________________________


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2099 Beaver Run Road Lewisburg, PA 17837

Phone: 570.523.8919

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