Program Registration Form

Primary Guardian’s Last Name

First Name

Address

City

State

Zip Code

Cell Phone

E-mail Address

Emergency Contact Name/phone

Check This Box

Check this box to receive emails from the Canton Park District that will include information about programs, events and classes at the Park District. We will not share or sell your email address. It is for Park District use only.

Check this box for Special Accommodations if needed. See “Statement of Accessibility” on the reverse side of this form. Please include a description of the type of special accommodation needed for successful inclusion so that we are better able to serve you.

I have read and fully understand the policies on the Canton Park District Waiver and Release form here. I understand my signature, or primary guardian’s signature if I’m under 18, is required to take part in Canton Park District programs.

REGISTRATION INFORMATION

Participant’s Name

Age

Grade

Birth Date

Program Name

Fee

Participant’s Name

Age

Grade

Birth Date

Program Name(Required)

Fee

Participant’s Name

Age

Grade

Birth Date

Program Name(Required)

Fee

Participant’s Name

Age

Grade

Birth Date

Program Name(Required)

Fee

Participant’s Name

Age

Grade

Birth Date

Program Name(Required)

Fee

Participant’s Name

Age

Grade

Birth Date

Program Name(Required)

Fee

To Submit Program Registration Form:

Mail or Drop Off in Person: Baker Recreation Center & Big Creek Park Pool, 940 N. Main St, Canton IL, 61520
Online registration is available at www.cantonpark.org

All programs are to be paid in full at time of registration. Fees can be paid by check, cash, gift card, or credit card. Please make checks payable to Canton Park District.

Once the form is submitted, you will be taken to the payment option.

Questions Contact Amanda Atchley - a.atchley@cantonpark.org or (309) 647-7665