Amy Gunn
c/o Art in the Country
18238 Windsor Hill Drive
Olney, MD  20832

Questions?  Contact Amy at amy@oldsagefarm.com.

Make checks payable to:  Old Sage Farm.

We will contact you by email or regular mail once we have received your registration form.  If you have any
questions, feel free to contact us.
Registration Form -- Old Sage Farm ONLY
Child's Name:
                     Date of Birth:
Parent's Name:
 
Home Address:
 
City, State Zip:
 
Home Phone Number:
 
Emergency Phone**
 

Does your child have any known allergies?  (Please indicate any allergies -- be as specific as possible.)  Include
bees, food and medications.



Does your child have any diagnosed medical conditions?  (This is strictly confidential information.  You do not have
to provide this.)



Does your child take any medication on a daily or "as needed" basis?  (This is strictly confidential information.  You
do not have to provide this.)



Are there any foods that you do not want your child to eat?  Please include soft drinks, juice, candy, bubble gum,
popsicles, crackers, etc.  (We provide light snacks daily.)





We look forward to working with your child this summer!  

**Please make sure that we are able to reach an adult at all times during the summer program.  We do not expect
any emergencies but must be able to reach a parent or guardian during one.
Email:
  
Please circle any programs that you are registering for.  If you are registering for different programs
for different children, please write their names next to the programs.
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Please indicate which session you would like to attend at Old Sage Farm:

Session 1:  July 12 - 16
Session 2:  August 2 - 6
Session 3:  August 16 - 20