St. Joseph, Illinois

 

 

 

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: ______________

Participant Information: Registration (Please fill out separate forms for each participant) 

 Child's Name

 (last name if different than above)

 

 Birth Date

(mm/dd/yy)

Sex

(Circle1) 

 Grade

(Just completed)

 Program Name

 Code

T-Shirt Size (if applicable)

 

Fee 
        week of June 13th  SD 101  YS YM YL AS AM AL AXL  $30
         week of June 27th  SD 102  YS YM YL AS AM AL AXL  $30
           
           

 

 
             Deadline to Register is June 9th  
             Total Fees  

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

 

5. 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                        Week 1                        

 

  Paid Cash                                             SCH                                                     Week 2                                                             Total Payment__________ Date ________