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Fort Klock Young Pioneer Program Application
August 6-8, 2019


Child’s name___________________________________ Age______ Grade entering in Fall _______
Parent or Legal Guardian_________________________________________________________________
Address____________________________________________________________________________________
Phone number___________________________(Home) _______________________________(Cell)
Email Address______________________________________________________________________
Please list any allergies, medical problems or medical conditions we
should be aware of:
______________________________________________________________________________________________

Child’s Physician: Name, number and address__________________________________________
______________________________________________________________________________________________
Hospital of choice__________________________________________________________________________
Emergency Contact & Phone #___________________________________________________________

Authorization for Medical Treatment

I,____________________________ as parent or legal guardian authorize my child ______________________________, to participate in the Fort Klock Young Pioneer Program held August 6-8, 2019. This program will include use of equipment, facilities and necessary preparatory activities. In the event or need for medical attention, I authorize Fort Klock Historic Restoration’s staff to call an ambulance or take my child to a doctor or hospital for treatment if necessary.

Authorization for Photos

I,____________________________, as parent or legal guardian give permission for my child’s photo to be taken for local newspapers as well as Fort Klock Historic Restoration’s use in promoting the Young Pioneer Program and Fort Klock.

Signature of Parent or Legal Guardian__________________________________________

Date_________________

The fee for $35 for non-members, $25 for Active Members. Please make checks payable to Fort Klock Historic Restoration.

Mail this application, along with payment to:

Fort Klock Historic Restoration
PO Box 42
St. Johnsville, NY 13452

For more information call 518-568-7779, email fortklock@gmail.com or find us on Facebook.

1-518-568-7779

P.O. Box 42 St. Johnsville NY 13452
Fort Klock, historic fortified home to the Klock family. Located in western New York colony, 1750.

Fort Klock Historic Restoration in the Mohawk Valley, New York Colony 1750