Family Days Application

 
Please enter the following information about the applicant.
Applicant Phone *
Applicant Phone
Applicant's Date of Birth *
Applicant's Date of Birth
Indicate the types of activities the applicant would prefer to participate in at the farm. *
Indicate the types of activities the applicant would prefer to participate in at the farm.
We will do our best to accomodate your needs and preferences.
I want to interact with new people while doing farm activities.
I want to participate in quiet, non-interactive activities.
I want to participate in activities that involve walking and standing.
I want to be sitting down while participating in farm activities.
I want to participate in activities that involve fine motor skills.
With which program did the applicant previously visit Empower Farms? *
If the applicant has not visited the farm before, select Other/None.
Please enter the following information about the applicant's parent/guardian.
Parent/Guardian Phone *
Parent/Guardian Phone
If different from applicant's address
Will the parent/guardian accompany the applicant to the program? *
If another person will accompany the applicant, please enter his/her information.
Accompanying Person's Phone
Accompanying Person's Phone
Image Release
Read the following statement and check the box below. Then type your name to sign. *
I hereby grant to Empower Farms the right to take photographs and videos of me while participating in Empower Farms programs and events. I authorize Empower Farms to edit, copyright, distribute, and publish these materials in print and digital publications, without payment or any other consideration. I agree that Empower Farms may use such photographs and videos of me for the purposes of publicity, illustration, advertising, website content, social media content, newsletters, and any related lawful purpose. I understand and agree that these materials will become the property of Empower Farms.
Type your name in the box below to sign the image release.
Type your name in the box below to sign the image release.