register at mortongroveparks.com | 2018 Fall Activity Guide
57
HE
FORM
Household Enrollment Form
YOU MUST CREATE A HOUSEHOLD ENROLLMENT ACCOUNT PRIOR TO REGISTERING ONLINE.
Help us help you in creating your NEW Household Account.
COMPLETE this form and submit it to Prairie View Community Center.
PLEASE NOTE: TWO FORMS OF IDENTIFICATION WILL BE NEEDED TO SHOW PROOF OF RESIDENCY.
Prairie View Community Center, 6834 Dempster St, Morton Grove, IL 60053
Phone: (847)965-1200 Fax: (847)965-4115
mortongroveparks.com
PRIMARY GUARDIAN FIRST AND LAST NAME _______________________________________________________________________________________
ADDRESS ______________________________________________________ CITY _________________________ ZIP ________________
PRIMARY PHONE ______________________________________ OTHER PHONE _______________________________________________
EMAIL ADDRESS __________________________________________________________________________________________ BIRTH DATE __________
SECONDARY GUARDIAN FIRST AND LAST NAME ____________________________________________________________________________________
ADDRESS ______________________________________________________ CITY _________________________ ZIP ________________
PRIMARY PHONE ________________________________________ OTHER PHONE _____________________________________________
EMAIL ADDRESS __________________________________________________________________________________________ BIRTH DATE __________
ADDITIONAL FAMILY MEMBERS (FIRST AND LAST NAME) SCHOOL BIRTH DATE GENDER
M F
M F
M F
M F
M F
M F
M F
RESIDENCY VERIFIED □ STAFF INITIALS __________
