Young Pioneers Day Camp Registration Form 2016 Dan Nagle Walnut Grove Pioneer Village a Scott County Conservation site 18817 290th St. (rural) Long Grove, IA 52756 www.scottcountyiowa.com/conservation (563) 328-3283

Please complete a separate form for each child you are registering. Day Camp for children ages 6-12 years old. Child must be 6 years old & no more than 12 years old on or before June 1, 2016. Child’s Name ______Date of Birth______Age as of June 1, 2016 ______Parent/Guardian Name:______Address______Note: We take several hikes in Scott County Park each City______State _____Zip ______week, which is the reason for the age 6 restriction.

Email address:______Most communications are sent via email. Phone #: ______Alt Phone #______

Please list all the individuals that you authorize to pick up your child in addition to the parent/guardian listed above. Anyone not on the list will not be able to pick up your child unless we are notified by you in advance. Name______Relationship to Camper______Phone______Name______Relationship to Camper______Phone______Name______Relationship to Camper______Phone______If your child wants to be placed in the same small group (6-7 campers and 1 camp counselor) with a friend/relative, you have the option of listing a “Buddy” friend/relative here:______Child T-shirt size—circle one: Youth small Youth medium Youth large Adult small Adult medium Adult large Adult X large

Child Information & Parent Permissions Lunch: Monday -Thursday, child to bring sack lunch. NOTE: Field trip lunches should be in a disposable sack or zip lock bag with their name on it in order to fit into our iced down coolers. Friday’s lunch of a hotdog/chips & carrots/snack cookout is provided. Snacks: An afternoon snack is offered each day. Water bottles are provided on the first day of camp. Child’s Name______has the following medical restrictions/requirements: Allergies? Yes/No Type:______Medication for Allergies?______Special Instructions about medical restrictions:______Emergency Contacts: Name______Relationship to child______phone #______Name______Relationship to child______phone #______Child’s Doctor Name ______phone #______Dietary Restrictions? Circle one: Yes/No Explain______

Swimming: Every Friday we swim at the Scott County Park Pool. Child pick-up will be at 3:00 p.m. at the pool instead of the Village on Fridays. Late pick up will still be at the Village. Note: Lake swimming at West Lake Park will be on July 13. List any water restrictions here:______Child’s swimming skill level:______

Permission for child to participate in off-premises field trip(s)? Circle one: Yes / No Note: We utilize Johannes Bus Service for transportation. Permission for photos of child to be taken? (Newspaper, etc.) Circle one: Yes / No

Parent/Guardian Signature______Date______Page 1 of 2

Weekly Camp Themes & Payment Options Please complete a separate form for each child you are registering. Each week is limited to 50 children. Reservations are on a first-come-first-serve basis. Our ratio of children to camp counselors is 7-1. Choose one or any amount of weeks. Day camp is from 9 a.m. to 3 p.m. with drop off between 8:30 –9 a.m. and pick up between 3 - 3:30 p.m. fees are $100 first week, $95 for each additional week for same child. Note: we do not have a multiple child discount.

Need more time at camp? Early drop-off is from 7 - 8:30 a.m. and late pick-up is from 3:30 - 5 p.m. During this time children are supervised, however no formal activities are offered. Early drop-off and/or late pick-up is a flat fee of $130 first week, $125 for each additional week for same child. Questions? Call Dan Nagle Walnut Grove Pioneer Village Site Manager, Deborah Leistikow at 563- 328-3283

Enter amount due in week(s) chosen below of $100/$95 (from 9-3) or $130/125 (9-3 plus early drop off and /or late pick up.)

$______Week 1: Pioneer Adventures Week, June 13-17 Field trip to Sawmill Museum in Clinton & Windmill in Fulton, IL Wednesday June 15. Have fun playing pioneer games and learning about the pioneer experience.

$______Week 2: Weird Science Week, June 20-24 Field trip to Putnam Museum Science Center Wednesday June 22. Learn about science with experiments, crafts and games. Launch a 50 foot solar bag.

$______Week 3: Wild West Week, June 27-July 1 Field trip to Buffalo Bill Museum, LeClaire & Buffalo Bill Homestead on

Wednesday, June 29. See live Buffalo. Pan for gold & participate in a watermelon seed spitting contest!

$______Week 4: Early American Sports Week, July 11-15 Try golf at Glynn’s Creek Golf Course Tuesday & Thursday morning. Learn to play croquet, badminton, & horseshoes! Wednesday July13 go to West Lake Park for swimming & disc golf.

$______Week 5: Young Explorers Week, July 18-22 Hike in two Mississippi River parks on Wednesday July 20 with Bishop Hill “Fox Tales” performer Brian Ellis where he will likely take on the persona of Mark Twain on the river! Learn how to use a compass and blaze a trail in the wild!

$______Week 6: Native American Week, July 25-29 Field trip to Maquoketa Caves on Wednesday July 27. Learn about Native American history through games and crafts.

$______Week 7: Rivers, Lakes & Streams Week, Aug 1-5 Visit the Mississippi River Eco Tourism Center and ride a 25 person pontoon in the Mississippi River back waters, enjoy a pond study& the Eco Center on Wednesday, Aug 3. Learn

how to fish and canoe on Pride Lake in Scott County Park.

$______Week 8: Nature Week, Aug 8-12 Visit Scott County Conservation’s Wapsi River Environmental Education Center near Dixon, IA all day then stay overnight in the bunkhouse on Thursday Aug 11. Evening meal & breakfast included. Parents are welcome to attend evening meal and/or stay overnight.

$______Total for (Child’s name) ______Registration is not complete without payment.

Payment Options: Payment-in-full is due upon registration.

CHECK: Mail check with this completed form to: Pioneer Village Call 563-328-3283 if you have any questions. Camp, 18817 290th Street, Long Grove, IA 52756.

Type of card? Visa MasterCard Discover CREDIT/DEBIT: Enter credit/debit information in box to the right. Then send completed form by mail to address above or send PDF Card # ______in email to: [email protected]. Security Code #______Exp Date: Month____Year______

If you do not want to enter Credit Card info on this form, enter the Card owner name______phone number you can be reached from 9 a.m. to 5 p.m. Monday- Friday ______and we will call you to obtain Address______your credit/debit card information to complete the registration. City/State/Zip ______

CASH: Call office at 563-328-3283 to set up an appointment to deliver cash and completed form. If payment includes other children’s fees, list names here:

______Any payment option can be completed in person at the office. Please call 563-328-3283 to set up an appointment. Registration Fees are non-refundable. Page 2 of 2