2019 Spring Break Camp Registration
Spring Break Camp at Shelby Farms Park encourages children to connect with nature through exploration, discovery, and fun! Campers will learn about habitats and wildlife, participate in outdoor activities, and complete a variety of nature-related projects.
Child's First Name
Child's Last Name
City, State, and Zip Code
Is he/she a vegetarian?
List any dietary restrictions or food allergies.
Are there any medical conditions we need to know about for the participant's safety/well-being at camp?
Please list any allergies.
Please list any medications the camper is currently taking.
*Please note that our camp staff is NOT authorized to administer medication during camp. Please contact Christina Fortenberry at 901-222-7265 to make arrangements for your child if medication is needed during camp.
Please list any additional information that we should know about your camper.
Parent / Guardian (1)
Work Phone (1)
Cell Phone (1)
Email Address (1)
Parent / Guardian (2)
Work Phone (2)
Cell Phone (2)
Email Address (2)
Emergency Contact (other than Parent / Guardian)
Relationship to child
Phone Numbers (please list 2)
Physician's Name, Address, & Phone Number
Health Insurance Name + Plan Number
Hospital Preference In Case of Emergency
Parent/Guardian Pick-up Permissions
Please indicate which parent(s)/guardian(s) are allowed to pick-up the camper.
Authorized adults who may pick-up the child
Please list any additional family members or adults who have permission to pick-up the camper. You do not need to list the parents/guardians again, but please make sure to include your emergency contacts (and additional adults) here if you'd like them on your child's authorized pick-up list.
Enrollment is contingent upon a COMPLETE health form. Please give us a COMPLETE record of the participant’s immunization history by:
1. Uploading a copy of your child's vaccination records OR
2. Mailing a copy of your child's vaccination records to be received no later than Monday, March 4, 2019 to:
Shelby Farms Park Conservancy
6489 Mullins Station Road
Memphis, TN 38134
FEES + PAYMENT
Camp Fees (8:00am-3:30pm):
$125 (Park members OR 2nd child enrolled)
Aftercare Fees (3:30pm-5:30pm):
$25 (Park members OR 2nd child enrolled)
We accept MasterCard, Visa, Discover, and American Express. If paying by credit card, you will be contacted for payment over the phone. We also accept checks and money orders that are made payable to Shelby Farms Park Conservancy.
2nd Child Enrolled
Shelby Farms Park Member Number
Shelby Farms Park - Camp Kit
Are you interested in purchasing a camp kit which includes a Shelby Farms Park drawstring bag, color-changing water bottle, and two Park stickers? This package costs only $12 and will be given to your child upon arrival at camp.
Total Fee Due
Method of Payment
Check or Money Order
TERMS + CONDITIONS
Rules for participants are the same for everyone without regard to race, color, national origin, gender or disability. I understand that all campers will be treated as individuals, and respect will be shown for a range of abilities and behaviors. I agree that Shelby Farms Park Conservancy (SFPC) reserves the right to dismiss a child from Spring Break Camp whose special needs cannot be provided for at camp or whose conduct is not in the best interest of the camp program. I will notify the director if my child has any serious restrictions related to his/her participation in the Spring Break Camp. I agree to the following policies regarding program fees: Deposits are non-refundable; No refunds will be given for canceling within 5 business days of my child’s Spring Break Camp session; No refunds are given if a participant is dismissed from the Spring Break Camp due to disciplinary action; No refunds are given if participants leave early due to homesickness or personal commitments. Shelby Farms Park Conservancy has my permission to use photographs taken of my child while at Spring Break Camp for promotional purposes. I also give my permission for photos to be emailed to all of the parents/guardians of the campers.
I hereby give permission to SFPC to transport the camp participant named above off the camp property for the purpose of medical care or program activities as deemed appropriate by the camp director. I hereby authorize the camp director and Park staff to provide for and secure treatment of health issues that arise at camp for the camp participant named above. In the event I cannot be reached in an emergency, I give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injection, anesthetic or surgery for the camp participant named above. I understand that SFPC does not provide accident/medical insurance for the camp participant named above. Medical bills, including prescription drugs, will be the responsibility of the parent or guardian named below. I authorize SFPC to use any of my credit cards on file to pay for medical bills and/or prescription drugs.
Thank you for your registration!
Please send any questions to Christina Fortenberry at firstname.lastname@example.org or 901-222-7265
Send me a copy of my responses
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