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2. Camper's First Name*
3. Camper's Last Name*
4. Weeks of Camp*
   -- Select One --Week 1 Only (December 22, 23, & 26 2025)Week 2 Only (December 29 - 30 2025 & January 2, 2026)Both Weeks

   Fees are $100/child for both weeks or $60/child for one week

6. Camper's Date of Birth*
   Camper's Date of Birth
7. Camper's Age *

   Age of Camper As Time of Camp

8. Camper's T-Shirt Size*
   -- Select One --Youth Small (5/6)Youth Medium (7/8)Youth Large (10/12)Adult SmallAdult MediumAdult LargeAdult XL
12. Primary Parent/Guardian *

    First and Last Name

13. Primary Phone Number for Texting*

    Use XXX-XXX-XXXX format

15. Primary Cell Phone*

    Use XXX-XXX-XXXX format

16. Primary Work Phone

    Use XXX-XXX-XXXX format

18. Primary Parent/Guardian Address*
20. City*
21. State*
22. Zip Code*
26. Secondary Parent/Guardian

    First and Last Name

27. Secondary Phone Number for Texting

    Use XXX-XXX-XXXX format

29. Secondary Cell Phone

    Use XXX-XXX-XXXX format

30. Secondary Work Phone

    Use XXX-XXX-XXXX format

32. Click Here If Address is Same As Primary Contact

    1. Same As Primary

    If different, complete address below

34. Address
36. City
37. State
38. Zip Code
42. Is your child taking any medications? If yes, please list and state what for.*

    If none, type N/A

43. Does your child need any medications given during camp? If so, please state which medications and frequency.*

    If none, type N/A

45. Does your child have any allergies? Is so, please list below.*

    If none, type N/A

46. Does your child have any other medical conditions or behavioral issues staff should be aware of? If so, please detail below.*

    If none, type N/A

48. Any additional medical or behavioral information we should know?
52. Emergency Contact #1*

    First and Last Name
    
    (This person will be contacted after every effort has been made to contact the primary and secondary parent/guardian)

53. Relationship to Camper*
54. Emergency Contact #1 Phone*

    Use XXX-XXX-XXXX format

56. Emergency Contact #2

    First and Last Name
    
    (This person will be contacted after every effort has been made to contact the primary and secondary parent/guardian.)

57. Relationship to Camper
58. Emergency Contact #2 Phone

    Use XXX-XXX-XXXX format

62. The following people MAY NOT pick up my child from camp.

    Provide first and last names. If multiple people, separate names with a semi-colon

64. Photo of Persons

    This photo will help staff identify those people you listed as MAY NOT pick up your child from camp.

68. Electronic Signature Agreement*

    I hereby release and hold harmless the City of Shelbyville, the Shelbyville Parks and Recreation Department, and any sponsors, associations, or employees related to any program or activity from any liability for injuries, claims, or damages that may occur during my participation in such events, programs, or activities. This release extends to my heirs, estate, executors, administrators, assignees, and all members of my family.
    
    By checking the "I agree" box below, you agree and acknowledge that 1) your registration will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
70. Electronic Signature*
74. Registration Is Not Complete Yet

    Upon hitting submit, you will be redirected to our payment portal. 

    Registration will only be complete when we have received your registration form and received full payment online.

Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit

* indicates a required field