R egistration F orm 16028 127 th Street, Lemont, IL 60439 • 630-257-6787 LemontParkDistrict.org
Parent/Guardian First and Last Name ______________________________________ Address ______________________________________________________________ City _________________________ Zip Code _______________ Home Phone ________________________ Cell Phone _____________________________ Emergency Contact/Phone _____________________________ Email ___________________________________________________ Please describe any accommodations needed: __________________________________________________________________________________________________
Date of Birth
Participant’s First Name
Program Number
Grade
Program Name
Fee
TOTAL FEE $ ____________
YES, I would like to contribute $___________ to the Lemont Park Foundation Scholarship Fund. This fund assists children who demonstrate financial need to participate in LPD programs. (Program #900013) I have read and understand the waiver and release of information on the back of this form. My signature, or the guardian’s signature if participant is under 18 years of age, is required to participate in the Lemont Park District programs. Any faxed Cancellations/Refund Policy Lemont Park District reserves the right to cancel, postpone any classes or rentals, or combine classes as necessary. Classes may be canceled due to low enrollments. Refund requests must be submitted to The CORE desk staff in person or via phone, fax or email during normal business hours. Requests received via email after normal business hours will be dated for the next business day. Classes, camps, athletic leagues, or programs: The cancellation deadline for a full refund is 7 days prior to the start of the class/program. After that, a $10 processing fee for each class canceled and any other associated costs (uniforms, supplies, etc.) which have already been incurred will be deducted from the refund amount. No refunds will be issued after a class has begun. Aquatic Center Passes: No refunds will be issued after the first day the pool opens for the summer. Preschool: The Deposit Fee of $100 is NON-REFUNDABLE. CORE Memberships: There are no refunds for CORE Memberships. All cancellation requests will be processed the last day of the month and future billings will not occur. Senior Trips/ Events: A $10 processing fee for each trip/event canceled and any other associated costs (travel, food, tickets, etc.) which have already been incurred will be deducted from the refund amount. Medical Drops – Prorated refunds will be issued upon receipt of a note from a doctor stating the individual can no longer participate in the program. The refund will be prorated from the date of receipt of the doctor’s note. Credits or make-up classes are not available if a class is missed. If the Park District cancels a trip or program, a full refund will be issued.
registration forms/signatures will be considered the same as an original form. Signature________________________________________ Date_______________
OFFICE USE ONLY
DATE RECEIVED __________
STAFF INITIALS __________
REGISTRATION & DATE PROCESSED ____________________
PAYMENT TYPE DESTRUCTION STAFF INITIALS AND DATE _________________________
CASH__________
CHECK#__________
CHARGE TYPE____________ VISA, MASTERCARD, DISCOVER, AMERICAN EXPRESS
CHARGE ACCOUNT NUMBER_______________________________
EXP. DATE___________ CVV____________
AUTHORIZED SIGNATURE__________________________________________
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