Brochures Winter 2016-2017 | Page 95

Class Registration Form
PARK DISTRICT OF HIGHLAND PARK

Class Registration Form

Registrant Information ( Please Print in Ink )
OFFICE USE ONLY Facility : CIA / DC / HNC / RCHP / SVGC / WRC Payment : CASH / CK / VISA / MC / DISC / OTH Verified Total : $ __________________________________ ( CREDIT ONLY ) Last 4 Digits of Card : _________________ Staff Entering :____________________________________
REGISTRANT LAST NAME PARENT / GUARDIAN NAME ( FIRST & LAST )
ADDRESS CITY STATE ZIP
EMAIL ADDRESS 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 Jessie Blumberg at 847.579.4062 .
o Special Accommodations ADA Information ( Check if needed ) o Grant-In-Aid ( Please check box if grant recipient .) %_____ ( Recipient must show 2017 verification card at time of registration .)
Activity
Registrant ’ s Name ( Last , First )
Number
Activity Name
Fee
Birthdate ( mo / day / yr )
Gender
I would like to make a donation to the SMILE Family Assistance Fund : o $ 5 o $ 10 o $ 25 o Other Amount ___________________
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 )
Total
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 .