Villa Park Recreation Online Registration Application

Please check here if new address

Family Last Name __________________________

Address _________________________________

City________________State______Zip_________

Home Phone___________Work Phone__________

Emergency Name___________________________

Emergency Phone___________________________

Please check the area where you reside within the village:

North of North Avenue

North of St. Charles to North Avenue

North of Madison to St Charles

North of Roosevelt to Madison

South of Roosevelt

Non-Resident

Please list the full names and birthdates of all household members. Online Registrations will only be processed for those individuals listed on this application.

Full Name and Birthdate:	Full Name and Birthdate:
1.__________________________________	2.__________________________________
3.__________________________________	4.__________________________________
5.__________________________________	6.__________________________________
7.__________________________________	8.__________________________________
9.__________________________________	10._________________________________

Payment for registrations made through The Villa Park Recreation Department Online Registration Program must be made by Visa or MasterCard. The Visa or MasterCard information listed below will be used for all Online Registrations received for those individuals listed above. The Villa Park Recreation Department reserves the right to cancel Online Registration privileges if the Visa or MasterCard listed below is ever declined when processing payment.

The following Visa or MasterCard account may be used for payment for all Online Registrations received by The Villa Park Recreation Department for individuals listed on this application.

Cardholder Signature:________________________________ Date:______________

Card Type(check one): Visa MasterCard

Account Number:___________________________ Expiration Date:_______________

Return to Online Registration Information Page