K-3 - Online Registration Participant Form - Carol Stream Park District

Step 1 of 3

Child's Name
First Last
Birth Date
MM slash DD slash YYYY
Age as of 9/1/2021
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Mother/Guardian's Name
First Last
Cell Phone
Additional Phone
Father/Guardian's Name
First Last
Cell Phone
Additional Phone

Authorized Contact & Release
Parents/Guardians with custody have authorization to pick up the participant. List siblings, parents without custody, relatives, or friends who are also authorized to pick-up your child. All individuals must present a photo ID in order for your child to be released into their custody. Only the custodial parent(s) may approve additions or changes to the Authorized Contact and Release List.
Parent/Guardian Name
First Last
Relationship
Email
Cell Phone
Additional Phone
Parent/Guardian Name
First Last
Relationship
Email
Cell Phone
Additional Phone
Do both parents have custody?
Pick up Consent - Contact 1
I authorize the Carol Stream Park District to release my child to the listed person in the event that I am unable to pick up my child myself. I release the Carol Stream Park District from any and all responsibility once my child has been released into the custody of these above individuals.
Authorized Contact 1 - Name
First Last
Authorized Contact 1 - Relation
Authorized Contact 1 - Phone
Pick up Consent - Contact 2
I authorize the Carol Stream Park District to release my child to the listed person in the event that I am unable to pick up my child myself. I release the Carol Stream Park District from any and all responsibility once my child has been released into the custody of these above individuals.
Authorized Contact 2 - Name
First Last
Authorized Contact 2 - Relation
Authorized Contact 2 - Phone
Pick up Consent - Contact 3
I authorize the Carol Stream Park District to release my child to the listed person in the event that I am unable to pick up my child myself. I release the Carol Stream Park District from any and all responsibility once my child has been released into the custody of these above individuals.
Authorized Contact 3 - Name
First Last
Authorized Contact 3 - Relation
Authorized Contact 3 - Phone
Pick up Consent - Contact 4
I authorize the Carol Stream Park District to release my child to the listed person in the event that I am unable to pick up my child myself. I release the Carol Stream Park District from any and all responsibility once my child has been released into the custody of these above individuals.
Authorized Contact 4 - Name
First Last
Authorized Contact 4 - Relation
Authorized Contact 4 - Phone
NOT AUTHORIZED TO PICK UP
NOT AUTHORIZED TO PICK UP 1 - Name
First Last
NOT AUTHORIZED TO PICK UP 2 - Name
First Last
Signature
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K-3 – Online Registration Participant Form

Step 1 of 3

Participant Information

Authorized Contact & Release

NOT AUTHORIZED TO PICK UP

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