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