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Walk In:


Drop Off: Mail In: On-line:


Fax It: Check one:


Family Last Name Address City


Name of emergency contact


First Name Last Name, (if different)


Birthday Grade Sex


Robert W. Rolek Comm. Center, 814 Hart Road in Round Lake or Sports Center, 2004 Municipal Way in Round Lake Beach


Box at Registration, 814 Hart Rd., Round Lake, IL 60073, Check or Credit Card 814 Hart Rd., Round Lake, IL 60073, Check or Credit Card Only


www.rlapd.org or www.roundlakeareaparkdistrict.org. Make checks payable to Round Lake Area Park District. Returned checks $15 service fee.


847-740-8180 Credit Card Only. When registering by fax, it is mutually understood that the facsimile registration document, (including the waiver and release of all claims), shall substitute for and have the same legal effect as the original form.


Resident, (process immediately)


Home Phone E-mail Address Zip


Relationship Program Name Code


Start Date


Non-Resident, (processing begins February 27) Work Phone


Cell Phone Emergency Phone Day Time Fee


Please list special accommodations you need to participate:


Please indicate if you will need inclusion services (Must fill out Inclusion Request Form) Would you like to donate to the “Fun”ds for Recreation Scholarship Program?


Yes / No Make checks payable to Round Lake Area Park District. Returned checks $15 service fee. Amount $ Total Amount of Programs $


Credit Card, (check one): Credit Card #


Payment Amount $


• Drop-off and mail-in forms are processed at random until class is filled.


• You will receive program confirmation by mail within 10 days.


• If a program is cancelled by the Park District, registrants will receive a full refund. Cancellations made by registrants more than 5 business days before the start date of a program will


receive a full refund minus 20% up to a maximum of $10.00. Yes! Visa


Please complete this portion if mailed or faxed in. MasterCard


Discover Expiration Date: Authorized Signature • Registration is not valid unless waiver is properly signed.


• Make checks payable to Round Lake Area Park District. Returned checks $15 service fee.


• Definition of Family: A family is defined as parents and their unmarried children, through 21 years of age, residing with them. Children, 22 years and older, as well as other relatives and/or individuals in the same household are NOT in the defi- nition of family.


Please send me an E-Newsletter. I’d like to receive more information on Park District Events and programs. E-Mail Address: _____________________________________________________________________________________________


I HAVE READ AND FULLY UNDERSTAND THE PROGRAM DETAILS, WAIVER AND RELEASE OF ALL CLAIMS AND PERMISSION TO SECURE TREATMENT ON THIS FORM.


Signature of Participant or Parent/Guardian :_________________________________________________ Date:_________________


Please print name of Parent/Guardian: ___________________________________________________________________ _________ A parent/legal guardian must fill out the registration form and sign the waiver for children under 18 years. If you’re not a parent, proof of legal guardianship is required in writing. Turn Over


Please see reverse side for Important Information P: 847-546-8558 | F: 847-740-8180 | www.rlapd.org | www.facebook.com/rlapd 111 101-112_BackPages_jg.indd 11 1/24/2017 9:02:11 AM


American Express Security Code:


REGISTRATION FORM


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