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REGISTRATION FORM PAYMENT INFORMATION MUST ACCOMPANY REGISTRATION Family Last Name: Home Phone: Address: Work/Emergency Phone:  City: Zip:  ACTIVITY NUMBER ACTIVITY TITLE ACTIVITY DAY & TIME START DATE PARTICIPANT'S FIRST & LAST NAME SEX BIRTHDATE (18&Under) FEE*             TOTAL:  Payment Information: Charge to: Debit card  MasterCard  VISA   Discover American Express Charge card account number:   Expiration Date 3 Digit Security Code (on back of card) Check here if the above address is new. Old address: American With Disabilities Act:  Special Needs?YES  NO A.D.A. Statement:  The Joliet Park District intends to comply with the interest and spirit of the Americans With Disabilities Act.  If you need any special accommodations, please call the Park District so that we may make the necessary arrangements for you.   Phone:  815-741-7275 x169 REFUND POLICY:  No refunds will be issued once programs begin without doctor's note or proof of relocation.  All requests must be in writing. LIABILITY:  The Joliet Park District assumes no responsibility for injury or loss of personal property.  It is recommended that participants make provisions for this coverage with their own insurance coverage. Registrants and participants permit the taking of photos and videos of themselves and their children during Park District activities and use as the Park District deems necessary. *FEE - If you have a valid Resident Discount Card, you will be charged the resident rate. Otherwise, the non-resident rate will apply.