St. Joseph, Illinois

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Village Office
207 E. Lincoln
St. Joseph, IL 61873
ph. 217-469-7371
fax 217-469-7019

Village of Saint Joseph Parks & Recreation

201 Second St., P.O. Box 716, St. Joseph, IL 61873 – (217) 469-9504 – Fax (217) 469-2673

REGISTRATION FORM

1. Parent/Guardian Information or Adult Participant - Fill out completely (please print)

First & Last Names: _____________________________________ E-mail:_______________________

Street Address: _______________ City: _Zip: _

Phone Home: __________Work: _ Cell: __________

Emergency Contact: ___________________________________ Emergency Phone: ______________

2. Participant Information – Registration (please fill out separate forms for each participant)

Name *(last name if different than above)*	Birth Date *(mm/dd/yy)*	Sex *(circle 1)*	Grade *(just completed)*	Program Name	Code	T-Shirt Size *(if applicable)*	Fee
		M F		Summer Daze – Session 1	SD 101	YS YM YL AS AM AL AXL	$125.00
		M F		Summer Daze – Session 2	SD 102*	YS YM YL AS AM AL AXL	$115.00
		M F		Summer Daze – Session 1	SD 101	ADD: $10 After April 15	$10.00
		M F		Summer Daze- Session 2	SD 102	ADD: $10 After May 15	$10.00
						TOTAL FEES

* SD 102 We will be closed on the 4^th of July

3. Does the Participant have any special considerations? (Allergies, medical conditions, dietary restrictions, etc) ______________________________________________________________________

4. Understanding of Risk – Read before signing

In consideration for the right to participate in Village of St. Joseph Parks and Recreation program activities I hereby agree to the following: I understand any recreation activity, including the one for which I am registering my child, involves certain risks to their personal safety and property or the safety and property of others. I agree to assume any and all risks associated with their participation in this activity, I further understand that participation in recreation activities requires certain skills and capabilities. I agree it is solely my responsibility to insure that my child’s health is adequate and their capabilities are sufficient to participate in these activities. In the event of an emergency, I give consent for my child to be taken to and treated at the nearest medical facility, understanding every effort will be made to contact the parent/guardian or emergency contact person listed above. In such event, I shall be solely responsible for all medical expenses associated with medical care. I agree to allow use of my/our photograph for program publicity. I have read and agree to the registration and program policies.

Parent/Guardian Signature________________________________________ Date______________

For office use only

Paid Check # ____________ R/NR Wait List Session 1

Paid Cash SCH Session 2 Total Payment__ Date

Registration Form 2012