Page 16 - DayCampBrochure2026

Register online at wdsra.com
Mail: WDSRA, 116 N. Schmale Rd.,
Carol Stream, IL 60188
Email: registration@wdsra.com
Registration Form Phone: 630-681-0962

Are you a new participant with WDSRA? □Yes □No

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 avoce information has changed: □

Pickup/Drop off
First Name Program Name Program Code Fee
Location
$

$

$

$

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 side 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 side to my minor child/ward.

Cardholder Name Card Number Exp. Date CVC Code Amount

16 REGISTER ONLINE: WDSRA.COM