Please complete form or go to www.scottcountyiowa.com/conservation and choose “Online reservations.” Online instructions

can be found on page 2 of this form, under Complete a separate form for each child.

Day Camp open to ages 6-12 years old.

Child’s Name ____________________________________ Date of Birth____________ Age as of June 1, 2019 ________

Child must be 6 years old & no more than 12 years old on or before June 1, 2019.

Primary Parent/Guardian Name:_____________________________________________________

Address_______________________________________________

City__________________________________ State _____Zip _____________

Email address:________________________________________________________Most communications are sent via email.

Primary Phone #: _______________________________________Alt Phone #____________________________________

List all people that you authorize to pick up your child in addition to the primary 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_____________________

Groups: Children are placed in groups by age: 6-7 year olds, 8-9, and 10-12. Name(s) of children your child wants to be

grouped with: (If none, leave blank) _____________________________________________________________________

T-shirt size (circle one): Child small Child medium Child large Adult small Adult medium Adult large Adult X large

T-shirts, water bottles, backpacks can be picked up at Open House on Thursday June 6 from 3-7 or Saturday June 8 from 10-2.

Lunch: Monday -Thursday, child to bring sack lunch in a disposable sack or zip lock bag with name on it. We refrigerate all

lunches. Friday’s lunch of a hotdog/chips/carrots/s'mores is provided.

Snacks & Water: Morning & afternoon snack is offered each day.

Child Information & Parent Permissions

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 #_______________

Dietary Restrictions? Circle one: Yes/No Explain___________________________________________________________

Swimming: Every Friday we swim at the Scott County Park Pool. Friday pick -up is at the pool at 3:00 p.m. Late pick up

kids are transported back to the Village at 3:15 p.m. for their regular pick up time at the Village.

Child’s swimming skill level/Restrictions:___________________________________________________________________

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, Conservation’s Facebook, etc.) Circle one: Yes / No

Parent/Guardian Signature__________________________________________________Date___________ Page 1 of 2

Young Pioneers Day Camp Registration Form 2019

Dan Nagle Walnut Grove Pioneer Village

18817 290th St. (rural) Long Grove, IA 52756

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Each week is limited to 50 children. Reservations are on a first-come-first-serve basis and NOT guaranteed without payment.

Choose one or any amount of weeks. Day Camp is from 9 am to 3 pm. Fees: $100 week or $130 week for before and/or after

care with drop off/pick up anytime between 7 am and 5 pm. $5 discount for each additional week child attends camp.

We do not have a multi-family member discount, only a multi-week discount. Questions? Call 563-328-3283.

Enter amount due below: First Week: $100 (9-3) or $130 (7-5). Second & additional weeks: $95 (9-3) or $125 (7-5).

June 10-14 $______Native American Field trip to Maquoketa Caves. Play Native American games. Make Dream catcher

& other crafts, enjoy visit from Native American performers.

June 17-21 $______Little House on the Prairie Field trip to Cinnamon Ridge Farms. Play pioneer games and explore the

world of early pioneer children’s daily activities such as making butter, candle dipping and more!

June 24-28 $______Weird Science Field trip to Discovery Depot in Galesburg including “Amazing Airmaze.” Make miniature

catapults, flying machines and dinosaur eggs. Launch balloon rockets and a giant solar bag.

July 8-12 $______Early American Sports Field trip to Li’l Mississippi Golf to play mini golf & water wars. Spend time at

Glynn’s Creek Golf Course for a golf lesson. Play croquet, badminton, horseshoes, kick the can and many more old American

games.

July 15-19 $______County Fair Field trip to Rock Island 150th County Fair. Help to create our own Walnut Grove carnival and

then spend an afternoon enjoying all the games of chance and skill.

July 22-26 $______Wild on Wildlife Field trip to Wapsi River Environmental Education Center to discover how animals

live. Make a rattlesnake tail and create-a-bat plus play many animal games. End the week doing the chicken dance and hokey

pokey animal dance!

July 29 – Aug 2 $______Dive In! Field trip to Whitewater Junction Aquatic Center AND an extra afternoon at the Scott

County pool! Make a shark tooth necklace, salt dough starfish and Popsicle holder plus play lots of water games.

Aug 5-9 $______Rivers, Lakes & Streams Visit the Mississippi River Eco Tourism Center and ride a 25 person pontoon in the

Mississippi River back waters, pond study & Eco Center. Go fishing & canoeing at Pride Lake with Naturalists from the Wapsi

Center.

$_________ Total for (Child’s name) ____________________________ Registration is not complete without payment.

Registration Fees are non-refundable, but can be applied to a different week if space is available.

PAY BY CREDIT/DEBIT ONLINE

Go to https://www.scottcountyiowa.com/conservation/pioneer-village/young-pioneers-day-camp and then select

"To Register: Online registrations can be made here." for the online registration page.

To view available camps select the “Day Camps” photo “hot button” at the bottom of the page.

To Register: Your user name and password should already be in our system if you used any Scott County Conservation ser-

vices in the past such as Day Camp, Swimming Lessons, Rentals or Golf. If not, you can create a new account.

If you have used any Scott County Conservation services, your primary phone number is already set up as your user name

and password. This phone number is either your home number (if any) or the cell phone number you have provided to us in

the past.

Questions? 563 328-3283 or email deborah.blad@scottcountyiowa.com.

PAY BY CHECK: Mail check with completed form to: Pioneer Village Camp, 18817 290th Street, Long Grove, IA 52756.

PAY BY CASH: Call office at 563-328-3283 to set up an appointment to deliver cash and completed form.

Weekly Camp Themes & Payment Options Please complete a separate form for each child you are registering.

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