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REGISTRATION FORM

Register online at www.wdsra.com Are you a new participant with WDSRA?
Mail: WDSRA, 116 N Schmale Rd., Carol Stream, IL 60188 O Yes O No
Email: registration@wdsra.com
Phone: 630­681­0962

First Name: _________________________ Last Name: _________________________ Age: _____ Birthdate:__________ Gender:_____

Address: __________________________________________ City: __________________________ Zip Code: _________________________

Billing Address (if different than above): ________________________________________________________________________________

Primary Phone: ____________________________ Mom Cell: ____________________________ Dad Cell: ____________________________

Parent/Guardian Name(s): __________________________________________ Disability: __________________________________________

Primary Email: _______________________________________________ Park District: __________________________________________

Emergency Contact: ____________________________ Emergency Phone: ____________________________ T­Shirt Size: __________

FIRST NAME PROGRAM NAME PROGRAM CODE PICK UP/DROP OFF LOCATION FEE

$

$

$

$

$

$

YOU MUST SIGN AND DATE THIS FORM FOR TOTAL $
YOUR REGISTRATION TO BE PROCESSED

________________________________________________ _______________________________________________ _____________

Printed Name of Person Signing Form Signature of participant (or parent/guardian if under 18) Date

I have read and fully understand the information on the reverse of this form, warning of risk, assumption of risk and waiver and
release of all claims. If registering a minor participant, I further attest that I have read the reverse to my minor child/ward.

CARDHOLDER NAME ACCOUNT NUMBER EXP DATE 3 DIGIT AMOUNT

40 REGISTER ONLINE AT WWW.WDSRA.COM