fall 2015v2.pdf

REGISTRATION FORMREGISTRATIONSeason: □ Winter□ FallIs this the first time you are registering for programs at the VHPD? □ No□ Yes – if yes, complete back of formFamily Last Name ________________________________ Primary Phone (______)_____________________Work Phone (_______)_____________________________ Secondary Phone (______)_____________________Address _______________________________________ Email________________________________________Your confirmation will be emailed to youCity _____________________________________ Zip _____________ School District #73: □ Yes □ NoEmergency ContactRelationship ________________________________Emergency Phone #1 (______)____________________ Emergency Phone #2 (_____)______________________I agree to the waiver on the back of this form. Signature_________________________ Date_______________Participant _____________________ Age _____ Birthdate ___________ Sex _____Grade (Fall ‘14) ________Check if this participant needs any accommodations, in accordance with The American with Disabilities Act, toeffectively participate in any of these activities.CODE PROGRAM FEE OFFICE USER / WInitials: Date:R / WR / WR / WParticipant _____________________ Age _____ Birthdate ___________ Sex _____Grade (Fall ‘14) ________Check if this participant needs any accommodations, in accordance with The American with Disabilities Act, toeffectively participate in any of these activities.Initials:Initials:Initials:CODE PROGRAM FEE OFFICE USER / WInitials:R / WInitials:Date:Date:Date:Date:Date:Registration FormR / WR / WInitials:Initials:Date:Date:Method of Payment: □ Cash □ Credit/Debit Card □ Check #_______ H/H credit_______Total Paid: $_________ All credit cards are charged & cash and checks are deposited as they are receivedMake checks payable to: Vernon Hills Park DistrictI authorize the Vernon Hills Park District to automatically charge the credit/debit card listed below for programregistrations offering a payment schedule - check applicable program(s): □ Preschool □ Swim Team □ DanceCharge To: Visa MasterCard Discover DebitAccount Number_____ _ ______ ______ ______ Exp Date __________Cardholder Name ___________________________ Amount $__________Authorized Signature______________________________________________All program cancellations must be made in writing ten working days before the start of the program.A $5 service charge will be assessed per registrant per program.Medical ConditionsPlease note any allergies, specialmedications, or additional conditionswhich may affect participation.Name:____________Comments: __________________________________OFFICE USE: Contact information verified in RecTrac_______________(initials)Play Longer, Live Stronger55