nssra registration form
How to register for nssra programs
Email your registration form to registration @ nssra . org Fax to ( 847 ) 579-5270 Drop Off or Mail to 1221 County Line Rd .
Highland Park , IL 60035 online at register . nssra . org
Participant ’ s Name : |
Age : |
Grade : |
New Participant ? |
� Yes |
� No |
If you ' re a new participant or if any information has changed since your last registration , 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 Transportation Information Subtotal Program Name Program Code Fee Transportation Code Fee
Subtotal Total from other side Deposits or Credits
� Yes , I would like to make a donation to NSSRA Foundation . To learn more about NSSRA Foundation , visit www . nssrafoundation . org Total
Complete payment information ( make checks payable to Northern Suburban Special Recreation Association ) � Mastercard � Visa � Discover � AMEX � Check Check number here :
Cardholder Name : Card Number : - - - CVV #: Expiration Date : Billing Zip Code : Amount of Charge : $ Authorized Signature :
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 .
Participant / Parent / Guardian Signature : Please Print Name : Date :
* 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 .
OFFICE USE ONLY : Registration Complete � Date : ____________ Time : ____________ Receipt #: _________________________ nssra . org / programs | ( 847 ) 509-9400