Arlington Heights Park District
Adult Basketball Registration Form

*** Full Payment Is Due With Registration ***
Print this form. Drop-off/mail your completed registration form with payment to:
Brien Halterman, Arlington Heights Park District,
410 N. Arlington Heights Rd., Arlington Heights, IL 60004
or FAX your registration form to 847-506-2735.

Team Name
Captain Name     Co-Cpt.Name
Street   Street
City Zip   City Zip
Phone (hm.)   Phone (hm.)
(wk.)   (wk.)
(cell)   (cell)
(fax)   (fax)
E-mail   E-mail
     
  Registration Fee $ 540.00 
  Number of Non-residents x $5.00 =
  Total Fee
 
Payment:
 Cash (must be in-person)
 Check
 Charge Card Information:
     Visa  MasterCard  Discover
      Cardholder No.
      Expiration Date
 
      Signature ______________________________
      (after printing, be sure to sign)