2016 Fall Registration Form
Mail or drop off to: NSSRA | 3105 MacArthur Blvd., Northbrook, IL 60062 (Be sure to include check or credit card information)
Fax: (847) 509-1177 • Email: registration@nssra.org
PARTICIPANT’S NAME: __________________________________________________ AGE: _________ GRADE: _________ ARE YOU A NEW PARTICIPANT?
YES
NO
If you answered yes or if any information has changed since last season, please complete this box accordingly:
ADDRESS: _____________________________________________________________________ CITY: ____________________________________ ZIP: _________________
PRIMARY CONTACT NAME/PHONE: ______________________________________________________________ EMAIL: ____________________________________________
PRIMARY EMERGENCY CONTACT NAME/PHONE: _______________________________________________________________________________________________________
PARTICIPANT’S SCHOOL/WORK: _____________________________________________________ TEACHER/CONTACT NAME: __________________________________________
SCHOOL/WORK PHONE: (
) ____________________________________________________ SCHOOL DISMISSAL TIME: __________________________________________
DIAGNOSIS: _________________________________________________________________________________
PARTICIPANT REQUIRES MEDICATION DURING PROGRAM
In addition to program sites, we have NSSRA pick up and drop off sites for participants. Please list your pick up and drop off codes below (see page 56). When signing up for optional transportation,
enter and total both the program and transportation fees listed on the program write-up. Sections below must be completed to process your registration.
PROGRAM INFORMATION
PROGRAM NAME
TRANSPORTATION INFORMATION
CODE
Cultural Arts Open House
FEE
467700-01
CODE
FREE
FEE
467700-51 FREE
PICK UP SITE
MOR
DROP OFF SITE
SUBTOTAL
PROGRAM &
TRANSPORT FEES
MOR
Yes, I would like to make a donation to NSSRA Foundation. To learn more about NSSRA Foundation, go to pages 50 - 51.
IF PAYING BY CHECK, PLEASE FILL IN YOUR CHECK NUMBER HERE: _________________________________
IF YOU ARE USING AMERICAN EXPRESS, DISCOVER, MASTERCARD, OR VISA, PLEASE FILL OUT THE FOLLOWING SECTION:
PLEASE CHECK ONE:
AMEX
DISCOVER
MASTERCARD
VISA
ACCOUNT NUMBER: ____________________________________________ V-CODE #: _________________
EXPIRATION DATE: _______________________ ZIP CODE: (NEED ZIP CODE # TO MATCH) __________________
Subtotal Fee Column:
Subtotal from Reverse Side:
Deposit:
Credits:
TOTAL DUE:
AMOUNT OF CHARGE: _____________________CARDHOLDER NAME: _______________________________
OFFICE USE ONLY:
REGISTRATION COMPLETE
AUTHORIZED SIGNATURE:__________________________________________________________________
DATE: _________________ TIME: __________
WAIVER AND RELEASE OF ALL CLAIMS
RECEIPT #: _____________________________
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.
If registering via fax or email, your
facsimile or email signature shall
substitute for and have the same legal
effects as an original form signature.
EACH REGISTRATION FORM MUST BE SIGNED
PARTICIPANT/PARENT/GUARDIAN: ____________________________________ DATE: ____________________
PLEASE PRINT NAME: ______________________________________________________________________
www.nssra.org
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