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Primary Guardian Information


First Name _________________________________________________________________________________________________________________ Last Name _____________________________________________________________________________________________________________________ Mailing Address (City/State/Zipcode) _________________________________________________________________________________________________________________________________________________________________________________________________________________________ E-mail _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Primary Phone ___________________________________________________________________________________________________________ Work/Emergency Phone __________________________________________________________________________________________________________________________________


____ ____ ____


Participant Information First & Last Name


Sex Date of Birth Grade Age Program Code


 F  M


 F  M


 F  M


 F  M


 F  M


Payment Information  Cash  Check enclosed, Check #________ (payable to Batavia Park District) Credit Card (NOTE: Credit card payments will only be accepted by phone, online or in person.) AMOUNT PAID $________________________


Persons with Disabilities


The Park District makes reasonable accommodations for persons with disabilities to participate. Please specify, in the space provided, any adaptive equipment, personnel or other accommodations you need to participate in a program for which you have registered. Please provide two weeks notice.


Yes! I Want To Receive The Batavia Park District E-Newsletter Signature Required


Participation will be denied if the signature of an adult participant or parent/guardian and date are not on this waiver. I have read and fully understand the assumption of risk and waiver and release of all claims (see reverse). Signature of Participant (18 years and up) or Primary Guardian


Date FAX this form to 630-879-9537 | See previous page for other registration options 


Yes! I would like to make


a donation to the Batavia Park District Scholarship Fund. $ _________________________


Program Name


Day/Date/Time


Fee


REGISTRATION FORM


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