Pono Grown Farm & Nature Camp Application Form

Camper's Name*

First Last

Camper's Birth Date*

Does camper have any allergies?*

Yes
No

Please list all allergies and describe camper's response to exposure.*

Does camper use an inhaler or epipen?*

Yes
No

Does camper have any health concerns or medical conditions?*

Yes
No

Please list all health concerns and medical conditions*

Also describe any necessary medications or treatments that may affect his/her participation at camp.

Does camper have any physical limitations?*

Yes
No

Please describe camper's physical limitations.*

Parent/Guardian's Name*

First Last

Relationship to camper*

Parent/Guardian's Phone Number*

Parent/Guardian's Email*

Preferred Communication Method*

Phone call
Text message
Email

We will contact you as little as possible, but want to make sure that when we do it's as easy as can be, so let us know how you prefer to be reached.

Additional Parent/Guardian's Name

First Last

Relationship to camper

Phone

Email

Emergency Contact Name*

First Last

Please name someone other than parent(s)/guardian(s) listed above. Parent(s)/Guardian(s) will be contacted first in case of an emergency. This gives us additional adults to reach out to in case we cannot reach you for some reason.

Emergency Contact's Phone Number*

Emergency Contact's Relationship to Camper*

Camper Photo Release*

I agree to have photos/videos of my child's camp experience taken and shared in future promotional efforts online and/or in print for camp.

Yes
No
I agree to have camper photos taken, but not publically shared

Liability Waiver*

I give consent for my child to participate in Pono Grown camp activities, and execute the liability release described herein on his/her behalf. I agree to assume responsibility for all risks, injuries, damages (known or unknown) associated with my child's participation in Pono Grown camp activities. I also agree to inform the camp coordinator of any actions or movements, which I feel my child cannot safely perform. I will inform the camp coordinator of any limitations, medical conditions, or other special considerations that may affect my child's safety during these camp activities in Makawao, Hawaii. I discharge in advance Pono Grown LLC, Olinda Road LLC, and all officers, employees, contractors, and volunteers from all liability related to my child's participation in and presence at camp. Furthermore, I forever waive any claim I, my heirs, or my legal representatives my have against the above mentioned persons and entities.

Consent for Treatment*

I give consent to have my child treated by emergency medical personnel, a physician, or surgeon in the case of sudden illness or injury while participating in Pono Grown Camp activities. I understand that any necessary medical treatments will be my expense.

Electronic Signature*

I have read the above parental consent form and waiver of liability, fully understand its contents, and agree to all of its terms and conditions. I agree that all the information contained in this application is accurate and will notify camp coordinator immediately with any changes.

My name entered here serves as my electronic signature*

Date*

Pono Grown Camp Options*

Waitlist for Full Day Camp 9 am - 3 pm Monday - Thursday
Waitlist for Half Day Camp 9 am - 12:30 pm Monday - Thursday

Full Day Camp Sessions

Half Day Camp Sessions

Camp Week Selection*

Select All
Week 3: June 15 - 18, 2020 waitlist
Week 4: June 22 - 25, 2020 waitlist
Week 5: June 29 - July 2, 2020 waitlist
Week 6: July 6 - 9, 2020 waitlist
Week 7: July 13 - 16, 2020 waitlist
Week 8: July 20 - 23, 2020 waitlist
Week 9: July 27 - 30, 2020 waitlist
Week 10: August 3 - 6, 2020 waitlist

Siblings*

Does camper have a brother or sister who also attending Pono Grown camp this summer?

No
Yes

Sibling Discount

Price: $0.00

Sibling Discount

Price: $0.00

CAPTCHA

Payment Options

No deposit is required to join the waitlist. If a space opens, a $100/week deposit is required to hold your camper's spot. We will hold your child's spot for 5 days after application is received. If payment has not been made within 5 days, their spot will no longer be reserved. The remainder of your balance will be due on the morning of the first day of camp for your child. This deposit is non-refundable except if the camp week(s) you've selected are canceled due to COVID-19 mandates. I plan to

Mail a check to Pono Grown at 677 Olinda Road, Makawao, HI 96768
Arrange to drop off cash
Pay by credit card with an additional 3% processing fee

Credit Card Processing Fee*

Price: $0.00

Credit Card Processing Fee*

Price: $0.00

Total

$0.00

Credit Card

Card Details

Cardholder Name