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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 theinterest and spirit of the Americans With Disabilities Act. If youneed any special accommodations, please call the Park District so that wemay 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 orloss of personal property. It is recommended thatparticipants make provisions for this coverage with their owninsurance coverage.

Registrantsand participants permit the taking of photos and videos of themselves andtheir children during Park District activities and use as the ParkDistrict deems necessary.

*FEE- If you have a valid Resident Discount Card, you will be charged theresident rate. Otherwise, the non-resident rate will apply.