OFFICE USE ONLY
Facility : CIA / DC / HNC / RCHP / SVGC / WRC
Payment: CASH / CK / VISA / MC / DISC / OTH
Verifi ed 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
EMAIL ADDRESS
PARENT/GUARDIAN BIRTH DATE (MO/DAY/YR)
CITY STATE
ZIP
PRIMARY PHONE 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.) % _____ (Recipient must show 2018 verifi cation card at time of registration.)
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.