Registration Form
Mail or drop off to : NSSRA | 1221 County Line Rd ., Highland Park 60035 Fax : ( 847 ) 509-1177 • Email :
registration @ nssra . org Please be sure to include check or credit card information .
PARTICIPANT INFORMATION
Participant ’ s Name : ____________________________________________________________ Age : _______ Grade : ______ New Participant ? Yes No If you answered yes or if any information has changed since last season , please complete the fields below : Address : ______________________________________________________ City : ____________________________________ Zip : ___________________ Primary Contact Name / Phone : ___________________________________________________ Email : ____________________________________________ Primary Emergency Contact Name / Phone : ____________________________________________________________________________________________ Participant ’ s School / Work : ___________________________________________ Teacher / Contact Name : ___________________________________________ School / Work Phone : ____________________________ Diagnosis : ________________________________________________________________________
Participant Requires Medication During Program
REGISTRATION INFORMATION ( Need more space ? Flip to the next page .) Program Information ( In-Person & Virtual )
Transportation Information
Program Code Fee Code Fee Pick Up Site Drop Off Site
SUBTOTAL
( Program Fees )
Waiver & Release of All Claims Please read this form carefully and be aware in registering yourself or your minor child / ward for participation in an NSSRA program , you will be waiving and releasing all claims for injuries you or your minor child / ward might sustain arising out of said program ( s ). I recognize and acknowledge that there are certain risks of physical injury to participants in a program , and I agree to assume the full risk of any injuries , damages or loss regardless of severity which I or my minor child / ward may sustain as a result of participating in any and all activities connected with or associated with such program ( including transportation services and vehicle operation , when provided ). I agree to waive and relinquish all claims I or my child / ward may have as a result of participating in the program against NSSRA and its officers , agents , servants , and employees . I do hereby fully release and discharge NSSRA and its officers , agents , servants , and employees from any and all claims from injuries , damage , or loss which I or my minor child / ward may have or which may accrue to me or my child / ward and arising out of , connected with , or in any way associated with the activities of the program . I further agree to indemnify and hold harmless and defend NSSRA and its officers , agents , servants , and employees from any and all claims resulting from injuries , damages , and losses sustained by me or my minor child / ward arising out of , connected with , or in any way associated with the activities of the program . In the event of any emergency , I authorize NSSRA officials to secure from any licensed hospital , physician and or medical personnel any treatment deemed necessary for me or my minor child / ward ’ s immediate care and agree that I will be responsible for payment of any and all medical services rendered . I have read and fully understand the above Program Details , Waiver and Release of All Claims and Permission to Secure Treatment .
Subtotal Fee :
Subtotal from Reverse Side : Deposit : Credits :
TOTAL DUE :
OFFICE USE ONLY : Registration Complete
Date : ____________ Time : ____________ Receipt #: _________________________
EACH REGISTRATION FORM MUST BE SIGNED * Participant / Parent / Guardian : _____________________________ Date : ___________________ Please Print Name : ____________________________________ * If registering by fax or electronically your facsimile or electronic signature shall substitute for and have the same legal effect as an original form signature .
PAYMENT INFORMATION : This Section Must Be Completed
If paying by check , please fill in your check number here : __________________
If you are using Mastercard , Visa , Discover or American Express , please complete the following section : Please check one : Mastercard Visa Discover AMEX Cardholder Name : _______________________________ Card Number : _______________________________ CVV #: ___________ Exp . Date : ___________ Billing Zip Code : ___________ Amount of Charge : $___________
Authorized Signature : ____________________________________________
Please add payment details if you are entering the lottery for in-person programming . You will only be charged if you are enrolled .