Page 25 - MPD_Summer_2018_Program_Catalog_Final-2

REGISTRATION FORM

*Please complete both sides of form*

Parent/Guardian Parent/Guardian
Last Name __________________________________________________ First Name _______________________________________
Address _____________________________________________________________________________________________________
City/Zip _____________________________________________________________________________________________________
Home Phone ______________________________________________ Cell Phone _________________________________________
Emergency Contact _________________________________________ Phone ____________________________________________
Email _______________________________________________________________________________________________________

Participant’s First Name OFFICE
Receipt # Date Last Name if Different from Age Program Fee USE
Parent/Guardian ONLY

Non-Resident Fee: $5.00 each program

Non-Residents check here to receive brochure by mail Total

Registration Policy: All registration must be completed, unless otherwise noted, by the stated deadline date. Registration will be taken
until a program has reached either its maximum or its deadline date. If a program is full, you may request to be put on waiting list for the
current season only. Those who have outstanding balances must settle their account before future registrations will be processed.
How to Register: By Mail: Complete the registration form in this brochure and mail to 397 S. State Street, Manhattan, IL 60442
In Person: At the Recreation Center - 397 S. State Street, Manhattan, IL 60442
After Hours: Place registration form and payment in the locked drop box outside the Recreation Center.
On-line: At www.manhattanparkdistrict.com
Cancellations/Refund Policies:
Please see details at: Manhattan Park District brochure or our Website: www.manhattanparkdistrict.com

Intending to be legally bound, I release all claims for damages to me or my child and give permission to participate in Manhattan
Park District programs and cooperative programs with other park districts. The Manhattan Park District, any other cooperative park
districts, and independent contractors assume no responsibility for injury or loss of personal property.

Signature: ____________________________________________________________________________ Date: ________________

Check or Money Order Payable To:
Please circle payment type:
Manhattan Park District
Billing Address Code: ___ ___ ___ ___ ___ Mail To:
Account #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Manhattan Park District • 397 S. State Street
Expiration Date: ___ ___ / ___ ___ SECURITY CODE: ___ ___ ___ Manhattan, IL 60442
Cardholder Name:________________________________________________________ Upon Receipt of Your Brochure:
Billing Address:__________________________________________________________ Mail-In, Fax-In 815.478.3428
Amount of Charge: $ __________________ On-line @ www.manhattanparkdistrict.com
Authorized Signature: ____________________________________________________ Or Drop Off Your Registration
(The MPD reserves the right to change a payment to reflect the correct fee.) NSF fee of $25 will be assessed for all returned checks.

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