Program Registration Form www.belviderepark.org


Date Registered:_______________________________ Parent/Guardian:______________________________ Address:_____________________________________ City___________________________Zip___________ Home Phone__________________________________ Cell Phone____________________________________ Emergency Phone______________________________ Contact Person________________________________ E-Mail:______________________________________ Participant’s First & Last Name


This section must be filled out if you are using a VISA or MASTERCARD


Account Number:


__________ __________ __________ __________ Cardholder Name:______________________________ Expiration Date: _______________________________ Authorized Signature:___________________________ M/F


DOB Program Code


Fee


TOTAL FEE


CHECK T-SHIRT SIZE (if applicable): Youth: YS


YM YL (circle one)


Adul t: Small Medium Large XLarge (circle one) School_________________________ Grade_________


Please list any special accommodations you may need:


_____________________________________________ _____________________________________________


The park district does not carry medical or accident insurance for program participation, therefore cannot be responsible for par- ticipant’s claims or damages. It is further understood that any participants that register for such activities assume all risk for liabil- ity regarding any claims or damages.


Belvidere Township Park District Photographs and Video Tapes Program participants. By registering for these programs, the partici-


pant consents to use by the park district of his/her likeness in park district advertising and other uses related to park district pro- gramming. Any action to enforce the terms of this contract, the prevailing party shall be entitled to reasonable attorney fees and court costs.


PARTICIPANT’S OR PARENT’S SIGNATURE _______________________________________________


(815)547-5711


The go Guide


53


REGISTRATION FORM


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56