Name: July 3rd Fireworks
Start: 2022-07-03T19:30:00+00:00
End: 2022-07-03T22:00:00+00:00
Location: Lan-Oak Park

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GENERAL INFORMATION

Family Name *

Address *

City *

State *

Zip Code *

Home Cell *

Cell Phone *

Work Phone

Email *

Emergency Contact/Relationship *

Emergency Contact Phone *

Please indicate if you have any special needs or require any accommodation

Are you a Lansing resident? *

Proof of residency may be required.

Yes

PAYMENT INFORMATION

Name on Credit Card *

Card Type *

MasterCard

Visa

AmEx

Credit Card Number *

Expiration Date *

CVC *

PROGRAM REGISTRATION INFORMATION

Please refer to the program brochure at the right for details about each program. If the desired program isn't listed, please register in person.

Participant 1 Name (P1) *

P1 Gender *

P1 Date of Birth *

P1 Program Title *

P1 Program Number *

P1 Section Number *

P1 Fee *

Participant 2 Name (P2)

P2 Gender

P2 Date of Birth

P2 Program Title

P2 Program Number

P2 Section Number

P2 Fee

Participant 3 Name (P3)

P3 Gender

P3 Date of Birth

P3 Program Title

P3 Program Number

P3 Section Number

P3 Fee

Participant 4 Name (P4)

P4 Gender

P4 Date of Birth

P4 Program Title

P4 Program Number

P4 Section Number

P4 Fee

Participant 5 Name (P5)

P5 Gender

P5 Date of Birth

P5 Program Title

P5 Program Number

P5 Section Number

P5 Fee

Participant 6 Name (P6)

P6 Gender

P6 Date of Birth

P6 Program Title

P6 Program Number

P6 Section Number

P6 Fee

Youth Scholarship Donation

TOTAL AMOUNT OWED *

Your credit card will be charged when registrations are processed.

Shirt Sizes *

Some, but not all of our programs, provide a t-shirt. Please provide t-shirt sizes for each participant.

Questions/Comments

Photo Release and Waiver

By filling out this form, I authorize the Lan-Oak Park District to use any and all photographs, audio, and/or video that contain my (or that of the participant, if filled out by a parent or guardian) voice, image, likeness, and/or image for promotional and/or publicity purposes. I hereby waive any right to inspect or approve the finished photograph, audio, video, advertising copy, or printed matter that may be used in conjunction therewith or the eventual use to which it may be applied. The Lan-Oak Park District will only use the aforementioned photograph, audio, and/or video, for promotional and/or publicity purposes (i.e. brochures, flyers, website design, cable television program, pamphlets, and/or any other form of media presentations used by the Lan-Oak Park District to promote and/or publicize its recreational programs and event offerings).

Registration Agreement *

I have read and understand the Waiver, Release of All Claims, and Hold Harmless Agreement for Lan-Oak Park District.

Click here for full Waiver, Release of All Claims, and Hold Harmless Agreement

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GENERAL INFORMATION

PAYMENT INFORMATION

PROGRAM REGISTRATION INFORMATION

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