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Oak Brook Park District Registration Form


Administ rat ion Of f ice | 1450 Forest Gate Road | (630) 645-9590 | regist rat ion@obparks.org Tennis Center | 1300 Forest Gate Road | (630) 990-4660 | tennis@obparks.org


Separate households require separate registration forms.


*Please indicate if a registrant has any dietary needs or requires any special accommodation or assistance for enjoyment of programs. Allow two weeks notice for accommodation. ____________________________________________ _________________________________________________________________________________________________________


Part 1 Primary Contact and Participant Information (Oak Brook Residency verification required)


Primary Contact (Full Name): ______________________________________________________Birth date (required): ______________________ Address _________________________________________________________________________________________________________________ City ___________________________________________________State ______________________Zip ___________________________________ Cell Phone # ____________________________________________Home Phone # ____________________________________________________ Email __________________________________________________ ☐ Check here if you are a Corporate Resident. (Letter REQUIRED)


PARTICIPANT’S NAME


BIRTH DATE MM/DD/YY


GENDER PROGRAM NAME CODE


$ $ $ $ $ $


Part 2 Payment Information & Authorization


Credit Card (If paying by card) ☐ Visa ☐ Mastercard ☐ Discover ☐ American Express Payment Amount: $_____________ Credit Card #: _______________________________________________________


Expiration Date:


Sign Here


/


Name of Cardholder:_________________________________ Authorized Signature: ___________________________________ Must have signature to be processed


By execution of this authorization, the undersigned herby gives the Oak Brook Park District permission to charge the credit card identified here-in for all charges accrued at the Oak Brook Park District for all listed Authorized Individuals. Patrons are responsible to notify the OBPD of any changes of address, credit card or expiration date information.


MY CHECK IS ENCLOSED. Please make checks payable to Oak Brook Park District. A $25 fee is charged for all returned checks. KEEP MY CARD ON FILE. Signature of Cardholder:_________________________________


or Part 3 Sign the Registration Form


Sign Here


I have read the program waiver stated on the back and understand that my signature is required in order to participate in any program. _________________________________________________________________________


Participant/Parent/Guardian Signature Signature MUST be included for Registration Form to be processed.


☐ I would like to make a donation (enclosed) to the Oak Brook Park District Foundation in the amount of $_________________ Te Oak Brook Park District Foundation is a nonprofit (501c3) organization committed to assisting the Oak Brook Park District by securing


philanthropic support on its behalf to enhance the use, growth, and preservation of parks, open lands, facilities, and programs. *Make checks payable to Oak Brook Park District Foundation.


______________________________ Date


FEE


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