Poco program intake form this form needs to be filled out by a parent/guardian before the first day on the farm Participating Child's Name * First Name Last Name Parent/Guardian Name * please put the name for the primary parent/guardian contact First Name Last Name Parent/Guardian Email * Parent/Guardian Phone # * (###) ### #### Allergies/Medical Conditions * does your child have any allergies or medical conditions? Medical Devices or Medications * does your child carry any medical devices or medications such as epipen or insulin? Child's Age * Emergency Contact #1 Name and Phone Number * Emergency Contact #2 Name and Phone Number * Authorized Rides * Please list all people authorized to pick up or drop off your child at Poco Farm Name and Phone Number of Child's Doctor * So we may contact them if we cannot reach your emergency contacts Thank you!