2019 Summer Brochure PDHP_Summer_2019_WEB_Final - Page 99

OFFICE USE ONLY Facility : CIA / DC / HNC / RCHP / SVGC / WRC / HPGLC Payment: CASH / CK / VISA / MC / DISC / OTH Verified Total: $ __________________________________ (CREDIT ONLY) Last 4 Digits of Card: _________________ Staff Entering:____________________________________ PARK DISTRICT OF HIGHLAND PARK Class Registration Form Registrant Information (Please Print in Ink) REGISTRANT LAST NAME PARENT/GUARDIAN NAME (FIRST & LAST) ADDRESS CITY EMAIL ADDRESS PARENT/GUARDIAN BIRTH DATE (MO/DAY/YR) PRIMARY PHONE STATE ZIP ALTERNATE PHONE/EMERGENCY CONTACT We encourage participation by everyone and provide reasonable accommodations in accordance with ADA standards. If you require program assistance for special needs, check the box to be contacted by our NSSRA Inclusion Liaison. For more information please call Natalie Liang at 847.579.3131 o Special Accommodations ADA Information (Check if needed) o Grant-In-Aid (Please check box if grant recipient.) % _____ Registrant’s Name (Last, First) Activity Number Activity Name Fee Birthdate (mo/day/yr) Gender I would like to make a donation to: o SMILE Family Assistance Fund o Parks Foundation of Highland Park o $5 o $10 o $25 o Other Amount ___________________ Total Payment Information o Check o VISA, MasterCard or Discover (In-person only) o Debit Card (In-person only) o Cash (In-person or drop-off only) Make checks payable to the Park District of Highland Park. Mailing address: Park District of Highland Park, Attn: Registration, 636 Ridge Road, Highland Park IL 60035 I have read and fully understand the important information on the back of this form including warning of risk, assumption of risk and waiver and release of all claims. Registration will not be processed without a signature. ________________________________________________________________________________________________________________ PARTICIPANT’S NAME (PLEASE PRINT) ________________________________________________________________________________________________________________ PARTICIPANT’S SIGNATURE (18 years or older or Parent/Guardian) DATE (MO/DAY/YR) NOTE: PARTICIPATION WILL BE DENIED if the signature of adult participant or parent/legal guardian and date are not on this waiver.