HomeMy WebLinkAboutSPI Registration ADA and FillableSPECIAL POPULATIONS
REGISTRATION FORM
Name
Address _________________
City __________________
State ___________ Zip _____
Phone __________________
Age ________ Birth Date _______
E-mail: __________________
Parent/Guardian /Counselor
Phone __________________
Emergency Contact Person
Address _________________
Phone __________________
Please (_L__) below the participant's type of disability.
This information is necessary to inform our S.P.I. staff of the
individuals enrolled in programs so that they may better structure
and develop activities , while at the same time it will assist our record
keeping. This information will be kept confidential and will only be
available to S.P.I. staff.
Developmental Disability
Physical Disability
Emotional Disability
Speech Impairment
Hearing Impairment Visual
Impairment Learning
Disability Wheelchair User
Other Health Impairments (specify)
Health and behavior concerns that may affect participation:
Please fill out this form completely . Mail or bring this form to the
Robert A. Lee Community Recreation Center, 220 S. Gilbert Street ,
Iowa City, Iowa , prior to three working days before the program begins .
Pre-registration is required , along with pre-payment in programs where
there is a fee. Make checks payable to Recreation Division . Please
register early as programs are filled on a first come basis . Only those
registered will be allowed to participate . Participants will be expected to
attend the activity on a regular basis . If unable to attend , please notify
the Recreation Division office , 319-356-5100 . Online registration
available at p:.,ww.1cgov .org/act1v1tyreg1straflon I
Program Registraton
Activity # Program Fee
Total:
PAYMENT INFORMATION:
Credit card : _________________
Credit card number: ______________
Expiration date: ________________
Three digit security code: _____________
Signature: _________________