2019 Woodland Discovery Adventure Camp Registration
Camp Fees: Nonmember: $200 / Park Member: $180
Session I: June 10-14 from 8:00am - 3:30pm
Session II: June 24-28 from 8:00am - 3:30pm
*Aftercare available from 3:30pm - 5:30pm for an additional cost
*Questions? Call 901-222-7265 or email Christina Fortenberry at email@example.com
Child's First Name
Child's Last Name
Date of Birth
Home Address (street, city, state, zip)
Is he/she a vegetarian?
List any dietary restrictions or food allergies.
Please list any additional allergies.
Are there any medical conditions we need to know about for the participant's safety/well-being at camp?
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 Name (1)
Cell Phone (1)
Work Phone (1)
Email Address (1)
Parent / Guardian Name (2)
Cell Phone (2)
Work Phone (2)
Email Address (2)
EMERGENCY CONTACT INFORMATION (other than parent/guardian)
Emergency Contact (1)
Relationship to Camper (1)
Phone Number (1)
Emergency Contact (2)
Relationship to Camper (2)
Phone Number (2)
Physician's Name, Address & Phone Number
Health Insurance Name + Plan Number
Hospital Preference in case of emergency
AUTHORIZED PICK-UP LIST
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 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 contact(s) and additional adults who have permission to pick-up your child.
Enrollment is contingent upon a complete health form. Please provide us with a copy of the camper's immunization history by:
1. Uploading a copy of your child's vaccination records OR
2. Emailing a copy of your child's vaccination records to Christina Fortenberry at firstname.lastname@example.org
FEES AND PAYMENT
Camp Fee (8:00am-3:30pm)
- $200 non-members
- $180 Park members OR 2nd child enrolled
Aftercare Fee (3:30-5:30pm)
- $50 non-members
- $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.
*A $50 deposit (included as part of your total payment) is due within a week of your registration to hold your camper's place. The remaining balance is due by Friday, May 31st, 2019.
Discounts: Park Member or 2nd Child
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 Amount Due
Method of Payment
Credit Card: Please call me for payment
Check: I will mail a check
How did you hear about our camp?
Word of Mouth
INFORMED CONSENT, RELEASE, INDEMNIFICATION + HOLD HARMLESS AGREEMENT
I understand that outdoor activities entail known and unanticipated risks and that participation in Woodland Discovery Adventure Camp at Shelby Farms Park involves a certain degree of risk that could result in injury, paralysis, death, or damage to myself, my child, or to property. In consideration of the benefits to be derived and after carefully considering the risk involved, and in view of the fact that precautions will be taken to ensure the safety and well-being of all participants to the best ability of trained staff members, I agree and promise to accept and assume all of the risks existing in this activity. My or my child’s participation in any Woodland Discovery Adventure Camp is purely voluntary, and I elect to participate in spite of the risks.
I hereby release and waive any and all claims that I may have against Shelby Farms Park Conservancy (SFPC) and their employees, agents, representatives, or volunteers, arising from participation in Woodland Discovery Adventure Camp. I agree to fully indemnify and hold harmless SFPC and their employees, agents, representatives, and volunteers from any and all claims arising from my or my child’s participation in SFPC programs. This indemnification expressly includes any claims arising out of SFPC’s own negligence or fault or that of their employees, agents, representatives, or volunteers. I agree that the indemnification includes the amount of the claims, the expense of defending against the claims, court costs, and attorney fees.
I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms.
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 SFPC reserves the right to dismiss a child from Woodland Discovery Adventure 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 SFPC Woodland Discovery Adventure Camp. I agree to the following policies regarding program fees: Deposits are non-refundable; No refunds will be given for cancelling within 5 business days of the camp session; No refunds are given if a camper is dismissed due to disciplinary actions; No refunds are given if a camper leaves early due to homesickness or personal commitments.
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 all 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.
Shelby Farms Park Conservancy has my permission to use photographs taken of my child while at SFPC Woodland Discovery Adventure Camp for promotional purposes. I also give permission for photos to be emailed to all of the parents/guardians of the campers.
I (Parents/Guardian) have read and agree to all the conditions of this registration.
THANK YOU FOR REGISTERING!
Please send any questions to Christina Fortenberry at email@example.com or 901-222-7265
Send me a copy of my responses
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