Page 15 - Copy of SUMMER CAMP BROCHURE 2024 Final

WDSRA Summer Camp 2024
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 Yes No
Email: registration@wdsra.com
Phone: 630-681-0962
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: T-shirt Size:
Please check if any above information has changed

First Name Program Name Program Code Pickup/Drop Off Location Fee

$

$

$

$
TOTAL $

YOU MUST SIGN AND DATE THIS FORM FOR 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

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