Mundelein Park District Program Guide online special summer brochure 2020 | Page 12

Program Registration
1401 N. Midlothian Road, Mundelein, IL 60060
847.566.0650 • Fax [phone]
mundeleinparks.org
MUNDELEIN PARK &
RECREATION DISTRICT
Parent/Guardian's Last Name:
First Name:
Address: City/State/Zip:
Primary Phone: Email:
Cell Phone: Cell Phone Carrier:*
* For emergencies only
Date of Birth:
Prog #
Program Name
Day/Time
Participant's Name
Gender
Age
DOB
Fee
M
F
M
F
M
F
M
F
M
F
Please consider a small donation to Mundelein Parks Foundation. $
Remember to sign the waiver on back of this page. Total
$
Check here if you need any accommodations in accordance with the Americans with Disabilities Act to effectively
participate in any of our programs. If an Inclusion Aide is requested, please contact us prior to the start of the program.
Payment: We accept Visa®, MasterCard®, Discover® and American Express®. Checks also accepted (payable to Mundelein Park &
Recreation District). Insufficient funds fee: $25 for returned checks.
Email: By providing your email, you give MPRD permission to send you information on Park District events and programs. MPRD
does not share its email lists.
This area for office use only.
o Cash o Check (#
Receipted/entered by
) o
MC o Visa o DC o AMEX
(Auth #
Date Amount
)