Clear Creek Canoe / Kayak Excursion and Campout

Clear Creek Canoe / Kayak Excursion and Campout

A Shelbyville / Shelby County Parks Adventure
Name - Primary Participant*

First NameLast Name
Age*
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please list ALL the names and ages of others in your party (if applicable) and their paddling experience. Mark "Single" if no others in your party.*
All names and ages in party, list "single" if no others in your party.
NOTE: By placing above members on your registration, you are confirming them to your party, submitting payment for each, and take full responsibility of all members present.
Primary Contact Phone Number*

Area CodePhone Number
E-mail
List email to receive confirmation.
Swim Level 1-10 (1 being minimal ability)*
Do you have paddling experience? *

NoneYes, but very minimalYes, 5 or more timesYes, 10 or more times
Emergency Contact Information*

Name

Relation

Home PhoneCell Phone

Postal / Zip Code
Does any person in the party have any type of medical and/or allergy condition?*

YesNo
If yes, please explain:
Example: Heart condition, diabetes, allergies to food, medicine, latex, bee stings, etc.
Medical Care: In the event of a medical emergency, do you give permission for parks staff to seek further medical care via EMS or hospital? *

YesNo

Please Select	Quantity	Price
Primary Participant 16 & Up		$52.00
Additional Adult 16 and up in Same Household		$26.00
Additional Child 15 & under in Same Household		$15.00

Please Select	Quantity	Price
Primary Participant 16 & Up		$42.00
Additional Adult 16 & Up in Same Household		$21.00
Additional Child 15 & Under in Same Household		$10.00

Please Select	Quantity	Price
Primary Participant 16 & Up		$21.00
Additional Adult 16 @ up in Same Household		$11.00
Additional Child 15 & Under in Same Household		$5.00

Please Select	Quantity	Price
Primary Particpant 16 & Up		$16.00
Additional Adult 16 & Up in Same Household		$8.00
Additional Child 15 & Under in Same Household		$5.00

Please Select	Quantity	Price
Primary Particpant 16 & Up		$26.00
Additional Adult 16 & Up in Same Household		$13.00
Additional Child 15 & Under in Same Household		$7.00