Mundelein Park District Program Guide Winter2019_Spring2020 brochure_online | Page 73

Program Registration
1401 N. Midlothian Road, Mundelein, IL 60060
847.566.0650 • Fax [phone]
mundeleinparks.org
MUNDELEIN PARK &
RECREATION DISTRICT
Parent/Guardian's Last Name: First Name:
Address: City/State/Zip:
Primary Phone: Email:
Cell Phone: Cell Phone Carrier:*
* For emergencies only
Date of Birth:
Prog #
Program Name
Day/Time
Participant's Name
Gender
1.
Age
DOB
Fee
M/F
2nd Choice
2.
M/F
2nd Choice
3.
M/F
2nd Choice
4.
M/F
2nd Choice
5.
M/F
2nd Choice
Please consider a small donation to Mundelein Parks Foundation. Learn more about MPF on page 5 . $
Remember to sign the waiver on back of this page. Total
$
❏ Check here if you need any accommodations in accordance with the Americans with Disabilities Act to effectively
participate in any of our programs. If an Inclusion Aide is requested, please contact us prior to the start of the program.
Payment: We accept Visa®, MasterCard®, Discover® and American Express®. Checks also accepted (payable to Mundelein Park
District). Insufficient funds fee: $25 for returned checks.
Email: By providing your email, you give MPRD permission to send you information on Park District events and programs. MPRD
does not share its email lists.
This area for office use only.
o Cash o Check (#
Receipted/entered by
mundeleinparks.org
) o
MC o Visa o DC o AMEX
(Auth #
)
Date Amount
Winter 2019/Spring 2020
71