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Program Registration Form
Participant Name: Address
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Main Contact: Name Phone Email __________________________ _____________________________
Teens & Adults Virtual Res. Fee Non-Res. Fee
Month #1: 9/12 - 10/7 Month #2: 10/10 - 11/4 All 8 Weeks: 9/12 - 11/4 Post Season: 11/21 - 12/16 $25 $25 $25 $25 $40 $40 $25 $25
Teens & Adults Virtual Club Res. Fee Non-Res. Fee
Bakers Club $31 $47
Teens & Adults Programs Res. Fee Non-Res. Fee
Bowling I $101 $202 Bowling II $127 $254 Bowling Bonanza $47 $94 Basketball Skills & Drills $45 $68 Night Owls $64 $128 Pillo Polo $64 $80 Socialites $128 $256 Special Olympics Basketball $224 $336 Special Olympics Basketball
Individual Skills $124 $186 Sports Sampler $42 $63 Walking Club $46 $92
Recreation Boxes Res. Fee Non-Res. Fee
Leaf Candle Holder Box Wooden Ornament Box Recreation Box Delivery $25 $25 $20 $20 $5
Credit Card Type: (Check One)
Visa MC DC Amex Amount Charged to Card: ________________________________ Print Name on Card: ______________________________________ Card Holder Signature: ___________________________________ Account Number: _________________________________________ Verification Code: __________
Special Events Res. Fee Non-Res. Fee
Dreamers Paradise Nature Walk Monster Mash I Love the 90' s Dance Blanket Making Spooky BINGO Halloween Hip-Hop Dance Hoedown Dance with transportation without transportation Friendsgiving Dance with transportation without transportation Holiday PJ Party Feed the Hungry Dance $32 $64 $11 $22 $17 $34 $15 $30 $45 $90 $28 $56 $28 $56 $63 $126 $50 $100 $67 $134 $50 $100 $24 $48 $15 $30
Sensory Depot - Multi-Sensory Room Fee
1 - 30 Minute Session Punch Card - 5 Sessions Punch Card - 10 Sessions $10 $45 $90
Grand Total: ____________________
SWSRA Main Office
12521 S. Kostner Ave., Alsip IL 60803 Phone: 708-389-9423 Fax: 708-389-6458 www.swsra.org
