User Accounts need to be parent or guardian if participant is under 18.
First Name: *  (Primary Contact)
Last Name: *  (Primary Contact)
Middle Name:
Prefix:
Nickname:
Language:
Birthdate:
Gender:
Address: *
City: *
State: *
Zip: *
Residency: *
Phone: *  (ex: XXXXXXXXXX)
Health Notes:
Emergency Contact:
Emergency Phone:  (ex: XXXXXXXXXX)

Please list out all Allergies you have. : *
Participant disability. : *
Please share any additional information that can help us support you or your child. : *
Do you take and medication while at program? If so, please list. : *
What Park District/Village do you reside in? : *
Do you have a history of seizures: *
Does participant use a wheelchair or walker? Please specify and if so can the participant transfer? : *

     
Email: *
Password: *  
Verify Password: *  
Password Requirements: Between 8-16 characters, 1 alphabetic, 1 numeric, 1 special character (!@#^*-=), no spaces
Yes, I want to receive email updates on events and activities
Family Members: